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New Patient Intake Form
Child's information
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
*
Month
/
Day
/
Year
Reason for seeking therapy
Reason for services
*
What is your main concern? What is your primary reason for seeking Occupational Therapy?
Parent/Guardian Information
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Mobile Phone Number
*
Parent/Guardian Email
*
How'd you hear about us?
*
Do you have a medical referral for OT services from your Pediatrician?
If you are unsure or do not have one, please obtain one and have it faxed to 206-735-3778 so that we can expedite Intake Processing.
Yes
No
What insurance provider do you have?
*
Sprout and Thrive is
In-Network
with
Blue Cross Blue Shield, Premera, Regence, First Choice, & Tri-Care
. We can still provide OT services if your plan covers Out of Network (
OON)
benefits. We do not support Molina or Apple Healthcare plans at this time.
Treatment Preferences
Preferred day(s) of the week for evaluation
*
A one-time 75 minute appointment
Monday AM
Tuesday AM
Wednesday AM
Thursday AM
Friday AM
Friday PM
Preferred day(s) of the week for therapy sessions
*
Therapy sessions are held weekly for 50 minutes.
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Note: Appointments are on a first-come, first serve basis. Your preferred schedules may be or may not be currently available. After school appointment times often have a longer waitlist than daytime openings and are reserved for children 7+.
Next Steps
After submitting this form, you will receive an
email from Fusion Web Clinic
containing insurance intake paperwork. Once you complete that and
provide a referral
from your pediatrician, our Administrator will contact you to schedule your child's evaluation.
Thank you for choosing us—we look forward to helping your child thrive!
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