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Pontiac Office:

3000 Centerpoint Pkwy Pontiac, MI 48341

Dearborn Heights Office:

24142 W. Warren Road, Ste B. Dearborn Heights, MI 48127

Almost No Waiting for PT, Speech AND ABA SERVICES! CONTACT US TODAY!

Euro-Therapies

Almost No Waiting for PT, Speech AND ABA SERVICES! CONTACT US TODAY!

Euro-Therapies

Home
About Us
Pediatric Physical Therapy
ABA Therapy
Speech Therapy
Adult Physical Therapy
- Adult Therapy Process
- Patient Forms
Resources
Contact Us

Expert Speech Therapy at Euro-Therapies

Euro-Therapies Speech Intake Form-Pediatric

Contact Us

Name:

Address:

Date of Birth:

Age:

Diagnosis

Gender Assigned at Birth:

Height:

Weight:

School Attendance: Classroom

Homeschool

Grade Level

Free Text

Parent / Guardian 1

Name:

Address: (if different from patient)

Phone Number:

Email:

YES

NO

Free Text

Parent / Guardian 2

Name:

Address: (if different from patient)

Phone Number:

Email:

Free Text

Emergency Contact

Do you have other health problems?

If yes, please explain

Relationship:

Email:

Free Text

Patient’s Primary Physician

Name:

Address/Location:

Phone Number:

Free Text

Current Status

Primary Language at home:

Please estimate the number of words your child has in their vocabulary:

If 0-20, please list the words the child uses:

Please list all name of individuals that live with the child and their relationship to the child:

Do you have pets in the home: Names:

Please describe your child’s educational history (special education, accommodations in the classroom, para-assistance, etc):

How does your child communicate: Please choose from the list below

Verbally

Nonverbally

Communication Device

How does your child receive nutrition: Please choose from the list below

Orally

Nonorally

If non-orally, please specify:

Type

Location

Freq

Quantity

Free Text

Current Status Continued

What concerns are you having: Check all that apply

Other alt communication device

Speech Generating Device

Option 3

New Option

Poor Speech Intelligibility

Little or not yet talking

Concentration difficulty

New Option

New Option

Coughing, choking during eating and drinking

Tach

What are you hoping for the therapist to address:

What is your goal for your child’s therapy:

Communicate, regardless of how that is accomplished

NOP

Make words

Make age appropriate speech

Eat and drink without choking

Please list all medical diagnosis including previous speech/language or swallowing diagnosis

Free Text

Please list all surgical procedures and dates

Procedure

Date

Procedure

Date

Procedure

Date

Does the patient have a past history of any of the following:

Ventriculoperitoneal Shunt

Feeding Tube

Seizures

New Option

Vision / Hearing Problems

Tracheostomy Tube

Please explained checked boxes:

Please list any significant prenatal or birth history:

Please check all that apply:

Premature gest wks: ____

Low Birth Weight:

C-Section Planned

New Option

Pre-eclampsia

New Option

Emergent C-Section

New Option

New Option

Breech Birth

Poor Suction

New Option

New Option

Vacuum

New Option

Fax:

Please check all that apply:

Chronic Ear Infections

Tubes

Option 3

Poor Weight Gain

New Option

Poor Sleep

New Option

Reflux

New Option

Frequent Fevers

Frequent Antibiotic Use

Compromised Immune System

New Option

Cardiac Issues

Lyme Disease

Please list any significant allergies:

Free Text

To the best of your ability, please answer the following (when did the patient)

Fax:

Crawled:

Stood Independently:

First Word:

Walked Independently:

String together words:

Ran:

Dressed self:

Made Sentences:

Do you have any concerns about your child’s behavior: If Yes, please explain

Is your child currently receiving any other services

Speech Therapy

NO

Early Intervention

Occupational Therapy

Physical Therapy

Special Education

Free Text

Insurance Coverage

Subscriber DOB:

Subscriber DOB:

Contract # or Enrollee ID:

Group #:

YES

NO

Secondary Insurance:

Subscriber:

Subscriber DOB:

Phone number on back of card (physican’s)

Contract # or Enrollee ID:

Group #:

Parent or Guardian Printed

Date

Contract#:

Staff Initials

Thank you for contacting us.
We will get back to you as soon as possible.

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EURO-THERAPIES SPEECH INTAKE FORM-PEDIATRIC

SERVICE AREAS

Auburn Hills
Berkley
Beverly Hills
Birmingham
Bloomfield Hills
Clawson
Dearborn Heights
Farmington Hills
Ferndale
Lake Orion
Madison Heights
Novi
Oak Park
Oxford
Pontiac
Rochester
Rochester Hills
Royal Oak
South Lyon
Southfield
Troy
Waterford
Wayne

CONTACT INFORMATION

Pediatric Therapy Center

Phone: (248) 857-6776

Alt: (248) 857-7137

Fax: (248) 857-7102

Email: info@euro-therapies.com

Address: 3000 Centerpoint Pkwy Pontiac, MI 48341

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Pediatric Therapy Center

Phone: (248) 857-6776

Alt: (248) 857-7137

Fax: (248) 857-7102

Email: info@euro-therapies.com

Address: 4020 Venoy, Suite 1100, Wayne, MI 48184

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Adult Physical Therapy

Phone: (313) 277-5508

Fax: (313) 277-5535

Email: info@euro-therapies.com

Address: 24142 W. Warren Road, Ste B.

Dearborn Heights, MI 48127

Mon - Thu: 9:00 am - 6:00 pm
Friday: 9:00 am - 3:00 pm
Sat - Sun: Closed

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Discover Payment Accepted

Cash Payment Accepted

Check Payment Accepted

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