Intake Forms

Pediatric PT & OT Services - Seattle, WA
Pediatric Therapy

Prior to scheduling please complete our Intake Questionnaire, Contract for Services and Authorization for Exchange of Information (files below.)   

When completed please print and mail the completed forms to:

  • Seattle – 20310 19th Ave NE, Shoreline, WA 98155

We will notify you by e-mail or phone when the completed intake information is received. Receipt of the completed intake information will “officially” place your child’s name on our appointment list to schedule. Children are not on our appointment list until we receive the completed intake information. We always do our best to schedule therapy as quickly as we can.

When you open the Intake Questionnaires (Word Documents) it is important that you click on the option to “save” or “save as” before you complete the form.If you do not “save” the file on your computer the information you enter will not be saved and will be lost when you close the file.

Please keep the completed documents on your computer until we confirm receipt at our office. We recommend that you keep a copy of the intake forms for your records.

Intake Questionnaire - Birth to 36 months

Intake Questionnaire - Over 36 months

Contract for Services

Authorization to Exchange Information

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