Leaps And Bounds Therapy Pediatric OT Intake Form

Providing private Lactation and Pediatric Occupational Therapy services to Chester County and the surrounding areas

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Serving primarily northern Chester County, PA.

Please contact me if you are curious if I can come to your area!

484-258-3215
info@labtherapyllc.com

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* Required Field

Requested Service:	In Home Teletherapy
Parent Full Name:	*
Child Full Name:	*
Child Date of Birth:	*
Your Email Address:	*
Address Line 1:	*
Address Line 2:
City: * State: * ZIP: *
Phone Number:	- - *
Was your child born...	Full Term Premature Weeks
Delivery type:	Vaginal C-Section
Any complications during pregnancy or birth:
NICU stay?	Yes No Duration:
Tongue tie / oral restrictions?	Yes No I Don't Know
Torticollis?	Yes No I Don't Know
Allergy concerns?	Yes No If yes explain:
Other Medical History: (Please include any diagnosis, specialists that are currenlty following your child, or other relevant details.)
Parent/Caretaker Concerns:
School Level:	Daycare School Grade:
Teacher Concerns:
Previous or current Early Intervention services:
Any additional information or concerns: