Intakes

Welcome to the Sunshine Center Pediatric Therapy Automated Client Intake System. Please fill out the form below and a member of our team will contact you to schedule your first appointment. if you have any questions throughout this process, feel free to contact 918-615-6492, Ext 2.


In the box below, list:






Primary Guardian Info:

Primary Insurance Info:

Secondary Insurance Info:

 

Does child have an active school IEP

Date of last Therapy Visit

Date of last Evaluation

Do you have a copy of the Evaluation Report ?

Has your child received a swallow study ?

Has your child has received a hearing screening completed during the last 90 days ?

If yes, what was the hearing screening result ?

spec

Speech Therapy

occ

Occupational Therapy

phy

Physical Therapy

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