Intake Form — IICA Speech

New Patient Intake Form

Attention CA Residents: We are currently at capacity for all Medi-Cal plans and are not accepting new patients with a Medi-Cal plan at this time.

Patient Name

First Name

Last Name

Date of Birth

YYYY

Location

Primary Language

Name of Insurance Provider

Insurance ID

Subscriber Name

Date of Birth of Subscriber

YYYY

Who referred you to IICA?

Please include first and last name:

Name of Primary Care Physician

What services are you interested in?

Speech Therapy

Occupational Therapy

Feeding Therapy

What are your primary concerns for therapy?

Does the patient have any medical diagnosis?

Do you have any previous reports, assessments or evaluations from the past? WHEN and WHERE did they take place?

Primary Parent/Contact Name

Relationship to Patient

Email **If you have an older email like yahoo, hotmail, aol.. please consider using a different email as our server is not compatible with those emails.

Phone

(###)

###

####

Secondary Parent/Contact Name

Relationship to Patient

Phone

(###)

###

####

Availability

If you are recommended for services, what would your availability be? We are open Monday to Friday from 8am to 7pm.