10+ Pediatric Physical Therapy Intake Form Examples and Templates

Hi, I’m Dr. Lauren Baker, PT, DPT, ATC, MTC, and I run a cash based mobile pediatric physical therapy business. I’m literally obsessed with this style of therapy, having a flexible schedule, and all the things that come along with not having the barriers that a traditional insurance based clinic has.

That being said, starting out was kind of hard at first, mostly because I wasn’t quite sure what I was doing — but also because there was SO MUCH to create: intake forms, consent forms, and documentation templates.

After a year+ in business, I feel like I have it mostly under control from an administration standpoint and thought I would share my intake, consent, and documentation forms with other Pediatric PTs who want to move into the cash based mobile peds PT business too.

You see, some people might think that by sharing these forms I’d be creating more competition for myself — but I see the opposite. I see a world where babes are treated in the comfort of their own home with therapists who are able to treat them compassionately and with a high level of energy and support because they’re not burnt out.

So to me, that means we’ve got to convince more peds PTs to take the plunge (& the risk) — which results in making the whole process less scary.

This is my goal in sharing these forms. I hope they help.

Disclaimer: I created these forms myself as well as from some standard language provided by Simple Practice. As of 2022 they have not been reviewed by a lawyer. Use them at your own risk and I highly recommend consulting with a lawyer prior to using them.

Here are all of the forms you can download and use for free:

• Online Parent Consultation Consent Form

• Online Parent Consultation Intake Form

• Online Parent Consultation Documentation Template

• Covid-19 Waiver

• Good Faith Estimate

• Informed Consent for Pediatric PT

• Medicaid Release Form

• Pediatric PT Intake Form

• Pediatric PT Practice Policies

• Pediatric PT Privacy Policies (HIPPA)

• Release of Information

• Youtube Video Release

• Pediatric PT Evaluation Template

• Pediatric PT Progress Report Template

• SOAP Note Template
  

Using Pediatric PT Intake and Documentation Forms

For full disclosure, these pdf forms are in the format directly downloaded from my all in one system (EMR + online scheduler + credit card payment). I use Simple Practice, which I absolutely love because it is an all in one system that makes sending, e-signing, scheduling, and getting paid something I honestly barely even spend brainpower on.

You can use these forms to create your own in Simple Practice and if you are looking for an all in one system you can sign up for Simple Practice here. You’ll receive $100 off & I will also receive $100 if you sign up using that link.

I currently utilize the $99/month option but you could get started using the $69/month option. The one thing I do dislike about Simple Practice is that they included the google calendar sync in their 99$/mo pricing tier, which I absolutely need. Otherwise, I would still be in the 69/mo category. I would recommend others start with 69/month unless they absolutely need google sync.

Simple Practice does have its own app so if you have fewer patients or are okay with carrying over your appointments to your google calendar manually, it might be worth it to save $30/mo. You can do everything I do with the $69/mo plan.

are you a pediatric PT with a mobile peds business?

If you are a pediatric PT who operates a cash based or mobile business and are interested in being interviewed on my youtube channel, please reach out here. I love sharing mobile and cash based peds PT businesses.