Getting Started

New tHERAPY Client Intake Form

New Patient Intake Form

Date *

* Indicates required field

Client Name *

First

Last

Client Gender *

Client Date of Birth *

Parent/ Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Mobile Phone Number *

Home Phone Number *

Email *

Define Other if selected *

Child's Medical History/Diagnosis *

Primary Care Physician *

Primary Care Doctor's office *

Primary Care Doctor's office Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Care Doctor's office Phone Number *

Primary Care Doctor's office Fax Number *

Availability *

Additional Information *

Currently receiving OT/PT/ST elsewhere? *

Emergency Contact Name #1 *

Emergency Contact #1 Phone Number *

Emergency Contact Name #2 (someone that lives outside of the home) *

Emergency Contact #2 Phone Number *

Insurance Information

Policy Holder's Name *

First

Last

Date of Birth *

Insurance Carrier *

Policy ID *

Phone Number *

Group # *

Relation to Patient *

How did you hear about us? *

Submit

Consent for Treatment

Consent to Treatment

If you prefer to fill out a hard copy, click the button below to download and return to Crossway Pediatric Therapy via fax to at 704-847-2033 or mail to 9111 Monroe Rd. Suite 100 Charlotte, NC 28270.

Consent for Treatment pdf Form

Medical History Form

Client Case History Form

If you prefer to fill out a hard copy, CLICK HERE to download and return to Crossway Pediatric Therapy via fax to at 704-847-2033 or mail to 9111 Monroe Rd. Suite 100 Charlotte, NC 28270.

Patient Information/ Insurance Verification

Insurance Verification Form

If you prefer to fill out a hard copy, CLICK HERE to download and return to Crossway Pediatric Therapy via fax to at 704-847-2033 or mail to 9111 Monroe Rd. Suite 100 Charlotte, NC 28270.

HIPPA Compliance Form

Financial Policy

Financial Policy Form

If you prefer to fill out a hard copy, click the button below to download and return to Crossway Pediatric Therapy via fax to at 704-847-2033 or mail to 9111 Monroe Rd. Suite 100 Charlotte, NC 28270.

Financial Policy pdf Form

Release Exchange Information Form form

Release/ Exchange of Information Form

Therapy Prices

Please complete the following forms and return to Crossway Pediatric Therapy via fax to at 704-847-2033 or mail to 9111 Monroe Rd. Suite 100 Charlotte, NC 28270.

** Crossway Inc. requires that clients pay evaluation fees prior to the service. This payment will be applied to your account in the form of a credit when insurance reimburses the amount.

Services We Offer

Occupational Therapy

OT can help kids with various needs improve their cognitive, physical, sensory, and motor skills and enhance their self-esteem and sense of accomplishment.

Physical Therapy

Physical therapists use a variety of treatments to help build strength, improve movement, and strengthen skills needed to complete daily activities.

Speech Therapy

SLPs assess speech, language, cognitive-communication, and oral/feeding/swallowing skills to identify types of communication problems and the best way to treat them.

Welcome To Crossway! If you are just getting started with Crossway, or if you would like to become more informed about what we offer, we have created a Welcome Packet that you may download.

Welcome Packet

Families receiving services in the clinic, we ask that you arrive 5-10 minutes before your appointment and return to pick up your child at least 15 minutes before the completion of his/her session. It is important to the therapists at Crossway to provide the best treatment possible to each child and must therefore adhere to his/her schedule. If at any time you feel as though you have not received enough information about your child’s treatment session or overall treatment plan, please talk with your therapist and set up a family conference.

If your child is attending a 60 minute treatment session it will typically be laid out as follows:

1–5 minutes — Therapist will ask about the child’s week and inquire about any changes in schedule, difficulties outside the clinic, affects of prior treatments, and other pertinent information.
45–50 minutes — Your child will receive about 50 minutes of skilled therapy
5–10 minutes — The last portion of the session the therapist may ask you to observe the child and/or discuss the overall treatment session. At this time the therapist will typically provide strategies and/or “homework” to translate treatment activities across settings.

Many parents and guardians find it very beneficial to come to each treatment session with a notebook and pen to record information provided by the therapist. Throughout your child’s time at Crossway you should expect to receive various hand outs, homework assignments, resources, home exercise programs, etc. Crossway is here to address the needs of each child; however, strategies and activities must continue within the home and community for your child to reach his/her highest potential.

Getting Started

New Patient Intake Form

Insurance Information

Services We Offer

Occupational Therapy

Physical Therapy

Speech Therapy

Services

Company

Support