Peak Potential Therapy Homepage
HOLLY REIMANN, MA CCC-SLP
Peak Potential Therapy

Therapy Treatments & Resources for Families with Children
Affected by Autism & Related Disabilities in Cleveland / Akron Ohio.

10 Great Reasons to Choose Peak Potential Therapy
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CLIENT INTAKE FORM



Thank you for choosing to start services with Peak Potential Therapy.

By completing this Intake Form you are taking the next step to begin services. Confirm your request by clicking the SUBMIT button below. Someone will contact you by phone to schedule your family's FREE Intake Session and your child's regularly occuring treatment sessions. During your Intake Session you will receive an enrollment package, get to know your therapist, and develop your child's individualized treatment plan.

We look forward to working with you.

Child Information
First Name* Last Name*
Birth Date (m/d/y)*
Diagnosis
Year of Diagnosis    
Services Requested
Please provide us with a list of services your are interested in
Best Time to Contact
Time of day* Best phone number*
Parents & Guardian Information
Mother First Name* Last Name*
Father First Name* Last Name*
Guardian First Name Last Name
Contact Information
Main Contact:
Phone Home*
Phone Cell
Phone Work
Address 1*
Address 2
City* / State*
,
Zip* / County
,
Email*
Family Information
 All persons living in household now:
 Name  Age                     Gender  Relationship to Child
     Female      Male
     Female      Male
     Female      Male
     Female      Male
     Female      Male
Other Services
 If your child is currently receiving other services, please complete.
          Type of Service  Name of Agency  Contact Person  Phone Number
 1.
 2.
 3.
 4.
 5.
  I give permission to contact the above-mentioned persons to aid in coordinating services: Yes No
Developmental History
 Were there any problems during pregnancy? (bleeding, high blood pressure, etc.):

 Were there any problems during delivery? (length of labor, Caesarean, lack of oxygen, etc.):

 Birth weight:   lbs.

 If your child completed any of the following developmental milestones significantly late, please check:
Weaned Babble Speak First Word Speak in Phrases Walking

 If you noted any special problems in these areas, during your child's early years, please check:
Excessive crying Failure to thrive Temper tantrums Unclear Speech Ear infections
Surgery Other:  

 Is your child toilet trained? Yes No

 How much assistance your child requires to complete the following?
None
Little
Much
N/A
Eat with spoon:      
Eat with fork:      
Use a knife:      
Use scissors:      
Use a crayon/pencil/marker:      
Isolate pointer finger to press buttons:      
Open flip lid:      
Open twist cap:      
Manage hot food/liquid safely:      
Recognize basic safety signs:      
Medical Information
Child's General Physician's Name
Specialty Physician's Name & Title
Specialty Physician's Name & Title
Does your child have dietary restrictions? Foods/liquids?
What environmental allergies?
What physical/health limitations does your child have?
Has your child been hospitalized for any reason since birth? Yes No
    For what?   When?
List medications your child is currently taking:
Start Date Drug Name Reason Prescribing Physician

List medications your child has taken in the past, but is no longer, other than for normal childhood illnesses:
Why Discontinued Drug Name Why Taken Date Last Taken
Eductional Information
  Does your child attend school currently? Yes No 
  Name of School:   City:
  Number of days attend per week:   Hours attend per day:
  Any problems at school? Yes No 
  If yes, please describe:
Family Concerns
  What is your primary goal for your child?
  What two things does your child need to change to be more successful in school, the community, or at home?
  1.  
  2.  
Cultural Information
  What particular group or culture does your family identify with?   
  What specific religious or spiritual beliefs or traditions are important to your family?   
Appointment Request
                                       Day Time
1st Choice
2nd Choice
Are you flexible with the above times? Yes No
Are you planning on multiple sessions per week? Yes No
Payment Information
How will you be paying for services?
Would you like information about local and national grant sources?   Yes No
Would you like information about Special Needs financial planning? Yes No
Additional Information
 Please explain any further information that would be helpful in serving your child and your family better:

 We greatly appreciate your time in completing this intake packet!

We respect your privacy. Under no circumstances will we use your personal information for any purpose other intended.
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