FOCUS Therapy

NEW PATIENT INTAKE FORM

You can expect to spend about 25-30 minutes completing this form. (But hey - at least you don't have to worry about the pen-and-clipboard wrist cramp!)

We recommend using a desktop or laptop, rather than a smartphone, as this is a longer form & includes several requests for digital document uploads. Be sure to fill out all "Required" fields [indicated with *] before you click "Submit."

Records/Information You May Want to Have Handy:

  • Health insurance card (picture of front & back)
  • Parent & emergency contacts (names, phone numbers, emails, physical addresses ,etc.)
  • Medical provider details (primary care & specialists -names, addresses, phone numbers, treatments, etc.)
  • Medical history information (details on diagnoses, allergies, surgeries, illnesses, prescriptions, therapies, etc., as well as any corresponding medical records/assessments for conditions relevant to the therapy services being sought.)
  • School records (most recent IEP, 504 plan, behavior plan, formal assessments, etc.)
FOCUS Therapy Patient intake form

Can't Finish All at Once?

If you are not able to complete this form in a single sitting, you have the option at the bottom of any page to click "Save and Continue Later." This will provide you with a link that will allow you to pick up where you left off anytime within the next 30 days.

Note that submission of this form is only for patients who have already been in contact with our office staff at FOCUS. To send a general inquiry, please e-mail us at [email protected] or submit questions through our Contact Us page.

"*" indicates required fields

Step 1 of 7

CHILD'S INFORMATION

Child's Name*
Child's Date of Birth*
Gender*
If none, type N/A.
Child's Home Address*
What FOCUS Therapy services are you interested in?*
Check all that apply.
How did you hear about us?*