Fundamental Therapy Solutions
OKLAHOMA New Patient Intake Form

New Patient documents

First Name

Last Name

Date of birth

Gender

Services Seeking

Speech & Language

Occupational Therapy

Physical Therapy

How did you hear about FTS?

What are your primary concerns for your child?

Primary Language spoken at home? If there is a secondary, please list as well.

Parent/Guardian 1

Parent/Guardian 1 D.O.B

Relationship to child 1

Mother

Father

Grandparent

Foster Guardian

Aunt

Uncle

Parent 1 STREET Address (Ex. 100 NW 47th Ave)

Zip Code

City

State

Parent/Guardian 1 Social Security #

Parent/Guardian 1 Phone Number

Email

Parent/Guardian 2

Parent/Guardian 2 D.O.B

Relationship to child 2

Mother

Father

Grandparent

Foster Guardian

Aunt

Uncle

Parent 2 STREET Address (Ex. 100 NW 47th Ave)

City 2

State 2

Zip code 2

Parent/Guardian 2 Social Security # (REQUIRED!!)

Parent/Guardian 2 Phone Number

Email 2

Insurance Information

Medical Insurance Provider

Member ID

Insurance Card

**If your child has the Gardner Scholarship OR Step Up for Students, please enter student ID#

Appointment Reminder Consent

How would you like your appointment reminders? (PLEASE CHECK ONE)

Email Reminder

Text reminder

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