Neuro Client Intake Form

  • 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!

  • Are you seeking services through Neuro or MCT?*

  • 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!

  • Today's Date*
     / /
  • Are you seeking or have you been referred for the following services? (Check all that apply. Leave blank if the answer is no)*
  • Are you seeking or have you been referred for the following services?*
  • Have you/your child received OT and/or PT services elsewhere?
  • Have you/your child received OT, PT, and/or SLP services elsewhere?
  • If there are speech concerns, and a recent hearing test was done, please provide the date of that test.
     - -
  • Are you seeking or have you been referred for the following services? (Check all that apply. Leave blank if the answer is no)*
  • Is the client currently receiving mental health services elsewhere?

  • Client and Contact Information

  • Date of Birth*
     / /
  • Is the Client a Child or an Adult?

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

  • Format: (000) 000-0000.
  • Type:*
  • May we leave a detailed voice message on your phone?*
  • Interpreter Needed?*
  • If the client is a minor (17 and younger), with whom do they live?
  • Is legal guardianship of client through DHS?*
    • Caseworker Information 
    • Format: (000) 000-0000.
    • END 

    • Background Information

    • Have you/your child been seen at our clinics previously?*

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

    • Has a referral for services already been sent to us by your PCP?*

  • Client Intake and Contact Information

    Insurance Information
  • Is there Medical Insurance?*
    • Primary Insurance 
    • Subscriber Date of Birth*
       - -
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • END 
    • Is there Secondary Insurance?*
    • Secondary Insurance 
    • Subscriber Date of Birth*
       - -
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • END 

  • Client Intake and Contact Information

    Insurance Information
  • I wish to be placed on the waitlist for the following clinic locations:*
  • How did you hear about our clinic?*
  • Are you interested in receiving telehealth services if available?*

  • *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.

  • Should be Empty: