Therapy Application

Hidden

Date

Therapy being considered (check all that apply):*

Behavior
Music
Recreation

BASIC INFORMATION

Enter information below as it pertains to the individual served whom is requesting services.

Name of individual served:*

First Last

Date of birth of individual served:*

Case manager / Company name:*

Case manager email address*

Last four digits of SSN for individual served:*

Permanent address of individual served:*

Street Address Address Line 2 City State ZIP Code

Parent / Guardian name:*

First Last

Parent / Guardian email address:*

Primary phone number:*

Best contact days and times:*

Primary diagnosis:*

Reason for referral:*

DETAILED INFORMATION:

Answer the questions below to give us a better idea of the specific needs of the person applying for services.

Limitations with fine / gross motor skills?*

Yes
No

Difficulty completing tasks of daily living?*

Yes
No

Difficulty in meeting developmental milestones?*

Yes
No

Difficulty in sustaining attention to tasks?*

Yes
No

Difficulty applying skills learned?*

Yes
No

Limited in expressive / receptive language skills?*

Yes
No

Ability to speak using words?*

Yes
Some
None

Engages in sensory seeking behavior?*

Yes
No
Unknown

Difficulty imitating or engaging with others?*

Yes
No

Emotional / behavioral disturbances that create barriers to completing tasks?*

Yes
No

Challenges with responding positively to directions?*

Yes
No

Difficulty displaying expected emotional response?*

Yes
No

Any incident reports in the past 90 days?*

Yes
No

List any other therapies currently being received (OT, PT, SLP, behavior management, etc.):*

Is there a behavior plan already in place for other therapies being received?*

Yes
No
Unknown
N/A

Additional information:*

Consent agreement:*

I agree to the privacy policy.

By checking this box, I understand that this application is part of a screening process to determine if behavior management, music therapy, or recreational therapy is appropriate for the individual named in this application. I understand that completing this application does not guarantee therapy services will be provided by ADEC Inc. I understand that by completing this application, I am giving ADEC Inc. permission to contact me regarding therapy services.

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