Pediatric Therapy Service Agreement
Please complete this form to share the child’s details, caregiver contacts, service needs, and any information needed to begin pediatric therapy services.
Child Information
Child’s Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Name
Primary Therapy Needs or Concerns
*
Relevant Developmental or Behavioral Notes
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Foster Parent
Stepparent
Grandparent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Text Message
Email
Any of the above
Service Agreement Details
Selected Therapy Service Types
*
Speech Therapy
Occupational Therapy
Physical Therapy
Behavioral Therapy
Feeding Therapy
Developmental Therapy
Other
Preferred Start Date
-
Month
-
Day
Year
Date
Session Frequency Preference
*
Please Select
Once per week
Twice per week
Three times per week
Every other week
Monthly
As recommended by therapist
Other
Special Scheduling Notes
Medical and Safety Information
Current diagnoses or concerns
Allergies or sensitivities
Current medications
Therapy-related precautions
Mobility or communication needs
Mobility support
Communication support
Assistive device use
Visual support
Hearing support
Other
Emergency contact name
*
First Name
Middle Name
Last Name
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: