Established (Current) Patient Intake

It is the policy of Jacob’s Ladder Pediatric Rehabilitation Center, Inc. to consider all patients without regard to race, color, religion, gender, national origin, age, or mental or physical disability. Information obtained regarding any of these characteristics will be recorded solely for information purposes and will be considered only as required to determine the type and level of care to be provided.

Established (Current) Patient Intake

Please complete the information listed below if you are in a current episode of care or returning for a new episode of care at Jacob’s Ladder Rehabilitation Outpatient Center. First Steps families transitioning to outpatient services or previous patients who have not been seen for 12 months should fill out the "New Patient" intake. By clicking the "Submit" button below, you agree that all the information given in the sections is accurate and whole.

Step 1 of 11

Discipline(s)*
- Occupational Therapy
- Physical Therapy
- Speech Therapy

Insurance Company	Benefit Phone	Insurance ID#	Group #	Policyholder Name	Policyholder Date of Birth	Policy Holder Employer

Facility	Provider	Discipline	Minutes per week

Facility	Provider	Discipline	Minutes per week

Name	Dosage	Frequency	Reason for Taking

Established (Current) Patient Intake

Established (Current) Patient Intake

Step 1 of 11

Scheduling Information

Responsible Party / Guardian #1

Responsible Party / Guardian #2

Emergency Contacts

Insurance Information

Additional Patient Information

Health Information

Acknowledgment of Information

Photos for Internal Use

Photos for External Use

Authorization

Name	Relationship

Name	Relationship

Medicaid Branch	Insurance ID#

Diagnosis or Condition being Treated	Diagnosis Code	Diagnosis Date