Initial Information Form

OTA Initial Information

  • Primary Contact Information:

  • Secondary Contact Information:

  • If the answer to the above question is Yes, please respond to the next question.
  • If the client has had an evaluation elsewhere and you are able to send us a digital copy of that evaluation, please do so here.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc.
  • Client Information:

  • PCP / Insurance Information:

  • example: Mother, Father, Aunt, Uncle
  • Appointment Date and Time Preference:

  • Leave any additional comments below.
  • Please remember to complete the History Form.