Child Intake Form

HIPPA Required Field.
HIPPA Required Field.
HIPPA Required Field.

PHYSICIAN INFORMATION

HEALTH / MEDICAL HISTORY

(i.e. standers, bathing/toilet chairs, wheelchairs, strollers, feeding chairs, adaptive equipment, feeding utensils, etc.)?

DEVELOPMENTAL HISTORY

* Check only that applies and explain if possible.

FAMILY HISTORY

BIRTH HISTORY

HOME/ PLAY/ SOCIAL BEHAVIORS

EDUCATIONAL HISTORY

Allcare Therapy Services is an in-network provider with most major health insurance plans. We work directly with your insurance company.