Carter's Play Place Occupational Therapy 

New Patient Intake Form  

Parent/Guardian Name *
Parent/Guardian Name
Home Address *
Home Address
Parent Birth Date *
Parent Birth Date
Insurance holder
Primary insurance holder
Home Phone *
Home Phone
Mobile Phone
Mobile Phone
Preferred Contact Method *
Child's Name *
Child's Name
Child's Birthday *
Child's Birthday
Emergency Contact *
Emergency Contact
Other than parents
Emergency Contact Home Phone *
Emergency Contact Home Phone
Other than parents.
Emergency Contact Mobile Phone
Emergency Contact Mobile Phone
Primary Care Physician Name
Primary Care Physician Name
(Orthopod, Neurologist, Ophthalmologist, etc)
e.g., born premature, feeding difficulties, complications, etc.
By clicking on the "Submit" button below, you agree: I give consent for my child to undergo speech, occupational therapy, and/or physical therapy evaluations and participate in treatment outlined in the therapist’s plan of care.