Laugh and Learn


Client Intake Form

(Fields marked with * are required)

Basics


Your Name*
Last Name*
Nickname or preferred name
Gender
Birthdate
Known Allergies
Previous Therapy History

Guardian Information


Parent/Guardian First Name
Parent/Guardian Last Name
Marital Status
Email*
Address-line 1
Address-line 2
City
State
Zip/Postal Code
Home Phone
Cell Phone (Mother)
Cell Phone (Father)
Work Phone
Work Phone Ext
Who referred you to our office?
Preferred Session Times
School District
School Name
Type of Classroom
Telephone (School)
Insurance Subscriber
Primary Cover
Do you have a secondary coverage?
Insurance Subscriber date of birth
Insurance Subscriber Social Security Number
Insurance Carrier
Policy Number
Group Number

Files


Copy of insurance

IEP

Diagnostic Report