The Lark Center, Inc | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Preferred name

What name should we use

Date of Birth

mm/dd/yyyy

Gender

What pronouns should we use?

He/Him She/Her They/Them Other

Town of Residence

In what town do you primarily reside?

Reason for care

What is the reason for seeking care?

What concerns would you like support with?

Limited to 600 characters

What kind of care is being sought?

Is there a specific service that interests you?

Occupational Therapy Speech Therapy Mental Health Counseling (play therapy, art therapy, psychotherapy, etc.) Physical Therapy Feeding Therapy Social/Recreational Groups Day Programs (MeadowLARK or SkyLARK) Parent Support Not Sure/Other

Administrative

Referral source

How did you hear about The Lark Center?

Limited to 600 characters

Client Preferences

Preferred appointment times

What works best for your family for regular weekly appointments?

Morning (9:00-11:30) Afternoon (12:00-3:00) Evening (3:30-7:00) Mondays Tuesdays Wednesdays Thursdays Fridays

Comfort with dogs

Annie, our therapy dog, may be present. Please let us know if any member of your family is NOT comfortable with dogs.

What are the client's strengths and interests?

Please describe what the client does well and enjoys doing

Limited to 600 characters

What is the preferred way for our intake coordinator to contact you?

Please include the best phone number or email address to use during business hours

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.