Neuro Client Intake Form Logo

  • Intake Form

    Client Intake and Contact Information

  • If you are seeking services for more than one client, please submit a separate intake form for each individual. We look forward to supporting you and your family!

  • Medford Children's Therapy is located in Medford, Oregon only.

  • Client Intake Form

    Client Intake and Contact Information

  • Before You Begin

    • Our Intake Form has 3 pages and must be completed in one sitting.
    • It typically takes 10-15 minutes to complete.

    To ensure your form is fully submitted, please make sure you reach the final "Thank You" page. If you exit early or close the window, we won't receive your submission.

    If you're ready to begin, click the Next button below!

  • Client Intake Form

    Client Intake and Contact Information

  • For Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST), both an Intake Form and a referral from your Primary Care Provider (PCP) are required. You are welcome to submit the Intake Form first while you work with your PCP to have a referral sent to Neuro or MCT. 

    • Those whose insurance is Kaiser will be added to the waitlist without a referral. However, an OT/PT/ST referral from Kaiser will be required when you near the top of the waitlist and are ready to schedule.

    For Mental Health and Medical services, only this Intake Form is required.

    After submitting the form, you'll receive an automatic email sent to the correct address you provided. This email contains important next steps. 

    We look forward to supporting you and your family!

  • For Occupational Therapy (OT) and Physical Therapy (PT), both an Intake Form and a referral from your Primary Care Provider (PCP) are required. You are welcome to submit the Intake Form first while you work with your PCP to have a referral sent to MCT.

    • Those whose insurance is Kaiser will be added to the waitlist without a referral. However, an OT/PT/ST referral from Kaiser will be required when you near the top of the waitlist and are ready to schedule.

    After submitting the form, you'll receive an automatic email sent to the correct address you provided. This email contains important next steps. 

    We look forward to supporting you and your family!

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  • Client and Contact Information

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  • The Parent/Guardian should provide their contact information if the client is a minor.  Adult clients should enter their own contact information. 

    • Caseworker Information 
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    • Background Information

    • Who is the client's primary care provider or referring provider?  

  • Client Intake and Contact Information

    Insurance Information
    • Primary Insurance 
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    • Secondary Insurance 
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  • Client Intake and Contact Information

    Insurance Information

  • *Those whose insurance is Kaiser will be added to the waitlist without a referral. However, an OT/PT/ST referral from Kaiser will be required when you near the top of the waitlist and are ready to schedule.

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