Patient Intake Forms:
Birth to 24 months
2 years and older
Insurance Benefit Information
Feeding Intake Form
Exchange of Information Authorization
HIPPA Privacy Practices Form
Client Information Sheet
Welcome to Eastside Children’s Therapy! If you are interested in receiving services from our clinic please contact Carolyn Fisher or Carol King at 425-392-2346. To get the referral process started we need to obtain initial contact information and be able to talk with you your concerns and your child’s therapy needs. We will talk with you about the services we offer, scheduling, and answer any questions you may have. Please refer to the printable forms on the left side of this page.
After contacting our office, please complete the following items including the printable forms listed on the left side of this page and mail or fax them to us:
Depending on your child’s needs, additional forms may be mailed to you. Please feel free to include any previous evaluations, reports, etc. that you feel would be helpful in assessing your child. For a handwriting assessment, please include samples of writing, copying, dictation, composition, math and drawings.
- A referral from your child’s physician requesting; OT evaluation and treatment as needed. Please ask your child’s physician to fax the referral to: 425-392-0185
- Photocopy of the front and back of your insurance card
- Registration Form completed and signed at bottom (2 places)
- Patient Intake Form
- Insurance Benefit/Verification Checklist (complete top portion only)
- Signed Financial Policy
Questions about insurance authorization and insurance coverage should be directed to our billing department. Please call our billing department directly at 888-698-6488.
Once we have received your completed paperwork we will put your child on our waiting list. We will contact you within one week of receipt of your information to either schedule an appointment, or let you know the anticipated wait time. An assessment can take one or more sessions depending on your child’s needs.
Please contact us at firstname.lastname@example.org or 425-392-2346. with any questions you may have. We look forward to providing services for your child.