Pediatric Rehabilitation Service Intake Form
Patient Information
Child's Full Name
Date of Birth
Gender
Male
Female
Other
Primary Language Spoken at Home
Address
City
State/Province
Zip/Postal Code
Parent/Guardian Information
Name of Parent/Guardian
Relationship to Child
Phone Number
Email Address
Primary Care Physician
Physician Name
Phone Number
Referral Information
Reason for Referral
Who referred you to this service?
Medical History
Diagnosis/Medical Conditions
Current Medications
Previous Surgeries or Hospitalizations
Allergies
Rehabilitation Services Requested
Physical Therapy
Occupational Therapy
Speech Therapy
Other Services
Additional Information
Goals for Therapy
Other Comments