Pediatric Occupational Therapy Intake Form

Pediatric Occupational Therapy Intake Form


For private practice pediatric occupational therapists, this editable OT intake form provides a template for collecting information about your new occupational therapy client. 

  • Digital Download: Please download within 24 hours of accessing link.
  • Format: an editable Word (.docx) document
  • Pages: 5 pages 
  • Published: May 2016

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Additional Information

Sections include: 

  • Information about you and your child
  • Your insurance information
  • Your reason for contacting us
  • Getting familiar with your insurance information

(An authorization to exchange information section and a privacy policy are NOT included. NY Therapy Guide has a Notice of Patient Privacy Practices template available for purchase.)

About the Creator


Erin Brandenburg lives a vibrant life in Oregon. Some of her favorite healthy habits are yoga, meditation, rock-climbing, hiking, and dancing, especially to Cuban Salsa music. She also enjoys creative outlets such as cooking new recipes, making DIY products with essential oils, and arts and crafts projects.

Erin completed her master's degree in Occupational Therapy at Rockhurst University in 2012. It was not long after she began her career that she developed a passion for working with children of all ages. Erin enjoys networking with other pediatric professionals and strives to promote quality holistic care for children and their families.

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