ATA Intake Form

Child / Client Name: *
Please enter Child / Client Name

Date of Intake:*
Please enter Date of Intake

Mother/Caregiver:*
Please enter Mother/Caregiver

Mother Prefix: *
Please select one

Address: *
Please enter an address

(Tel. Home)*
Please enter a number

(Tel. cell): *
Please enter a number

(Tel. work): *
Please enter a number

Email: *
please enter email

Father Prefix: *
Please select one

Address: *
Please enter an address

Father/Caregiver:*
Please enter Father/Caregiver

(Tel. Home)*
Please enter a number

(Tel. cell): *
Please enter a number

(Tel. work): *
Please enter a number

Email: *
please enter email

Client DOB: *
Please enter DOB

School/preschool: *
Please enter school name

School grade:*
Please enter grade

Current Diagnosis:*
Please enter diagnosis

Primary Physician (Pediatrician): *
Please enter name

Physician's Phone: *
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Physician's Address:*
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How did you hear about A Total Approach?: *
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What are your main areas of concern you would like to have addressed?*
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Has your child ever received an evaluation or services for any reason (OT, PT, SLP, psychology, neuropsychology, developmental pediatrician, developmental optometrist, and audiologist)?*
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Does your child currently receive services (private or school-based)?*
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Is there anything else you would like the therapist to know?*
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We would like to give you a call at no cost to you to discuss your needs more fully. Please provide the best 3 times to receive a call back as well as the best phone number to use.: *
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Are we allowed to leave a message:*
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Completed By:*
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Date: *
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