PS Kids, Positive Support for Kids, LLC
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New Patient Intake

The online intake forms are here to expeditate your child's processing. You will be contacted within 1-2 business days.

* Required Fields denoted in red.
Patient Information:
First Name: Last Name: Gender: 
Address:  DOB: 
City: State:  Zip: 

Caregiver #1 Information:
First Name:  Last Name: 
Relationship: 
Preferred Contact #: 
Home #: 
Work #: 
Cell #: 
Email: 
*Email will not be used for spam, only official secure communication.
*PDF Version of this information, along with additional paperwork will be sent to this email address.

Caregiver #2 Information:
First Name:  Last Name: 
Relationship: 
Preferred Contact #:
Home #:
Work #:
Cell #:
Email:
*Email will not be used for spam, only official secure communication.

General Questions: (Check for Yes)
Check box if enrolled in Missouri Medicaid Plan: 
Is this a court ordered evaluation for therapy?: 
Does your child have and IEP or IFSP?: 
Has your child had an OT, PT, ST evaluation in the past year?: 

Primary Insurance Information:   **Please bring a copy of your insurance card to first visit.
Insurance Co:
Insurance ID:
Group ID: (If No group ID enter 'None')
Holder Name:
Cardholder DOB:
Related:
Provider Service Phone # (listed on back of card):


Pediatrician Information:
First Name:  Last Name:  Phone: 
Address: 
City:  State:  Zip: 




Medical History

If your child has one or more of the following medical diagnosis, please check:

If your child has an additional medical diagnosis please list (ie Cerebral Palsy, Down Syndrome, Hearing Impairment, Attention Deficit Desorder, etc.)
Please list pertinent Medical History (Complications at birth, special care, surgery, hospitalizations, or delayed milestones):
Please list all allergies, Including food allergies or asthma (PS Kids is Peanut-Free):

Occupational Therapy


Physical Therapy


Speech Therapy


Final Questions:
Please list any adaptive equipment your child uses (Wheelchair, walker, Orthotics, etc):
Please describe any visual deficits:
Please describe any Hearing deficits:
Describe any history of ear infections or ear tube placement:
Please list any prescriptions your child takes on a regular basis:
Please list any situations at home/school we should know about that may influence your childs performance:
What would you or your child like to gain by coming to PS Kids:
Additional Caregiver Concerns:
Please list all days and times you are available. Please be specific and list the earliest times you could arrive. (Appointments last about 60 minutes):
***Please keep in mind that 8am-noon and after 3:30 are our busiest times of the day. Listing all possibilities for appointment days and times is appreciated and will expedite scheduling. ***
 
How did you hear about PS Kids:


*If you do not wish to email this form please print this screen and mail or fax it to P.S. Kids, LLC
6022 S. Lindbergh
St. Louis MO 63123
Fax: 314-845-7752
Please enter a password:
Please confirm password:
**Password is for accessing generated PDF that will be emailed to "Caregiver #1 Email"  
 
     
 
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PS Kids, LLC    6022 S. Lindbergh, Suite 100, St. Louis, MO 63123