Getting Started - Chrysalis Therapy

If you aren’t sure if Occupational Therapy is right for your individual, please feel free to contact us directly with any questions you have before filling out this Intake Form.

Completing this form does not obligate anyone to start services.

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Thank you for your submission. We will reach back out to your shortly.

Today’s Date (MM/DD/YYYY)

Client First Name

Client Last Name

Client’s Date of Birth (MM/DD/YYYY)

Client’s Gender

Male Female

Primary Care Physician Name

Primary Care Physician Phone

Primary Care Physician Address

Primary Care Physician Fax Number

Primary Insurance Provider Plan Name

Secondary Insurance Provider Plan Name

(It is required for all families to verify their own benefit information prior to starting services)

Primary Contact Name

Contact Email (Portal Login will be sent here)

City

State

Zip Code

Primary Phone (xxx) xxx-xxxx format

What type of service delivery method are you interested in?

If Other is Selected Service Delivery Method, Please Explain:

If Stride is Selected Service Delivery Method, Please List Name of Treating BCBA and Clinic Child Receives ABA At:

What are your areas of concern and goals for this service?

How did you hear about us?