Intake Paperwork

To get started with services at Children's Therapy Network, please complete the following forms:

​General Intake Packet


Questionnaire for the applicable discipline: OT Questionnaire, SLP Questionnaire, MH Questionnaire, or PT Questionnaire


Prescription from your child’s physician to receive services: OT ScriptSLP Script, MH Script, or PT Script


If you are an older teen or adult seeking occupational therapy services, please fill out and return the following paperwork: 

Adult-Adolescent Intake Packet and OT Questionaire Adult Checklist


Evaluations completed within the past 12 months (one can also be completed by our staff)


Current IEP, if applicable


Copy of the front and back of your child’s insurance card


Any additional information you think would be beneficial for your child’s therapist to have

It is helpful to have the initial paperwork prior to the time of the evaluation, however, if this is not possible, please bring them to your first appointment. Intake paperwork can be faxed to (608) 819-6825 or emailed to


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639 Struck Street Madison, WI 53719     |     Tel: 608.234.5990   |     Fax: 608.819.6825   |     Make a Payment

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