FREE 5+ Physical Therapy Intake Forms in PDF | MS Word

Some results of illnesses, accidents, and diseases could not be cured and healed by expensive and regular medication. This is why physical therapy centers are built to cater patients who need to sustain and acquire their physical strength and well-being once again. The therapists in these therapy centers use physical therapy intake forms for their clients. The completed form will be recorded and documented to the database system of the therapy center. You may also see counseling intake forms.

• Medical Intake Forms
• Therapy Intake Forms

Physical Therapy Patient Intake Form Sample

What Is a Physical Therapy Intake Form?

A physical therapy intake form is a document that will collect the data of a physical therapy client or patient. This form should be completed by the patient as he arrives at the therapy clinic. With the completed form, the therapist will be able to determine and construct a suitable therapy session to cater the needs of the client in curing his physical difficulties. You may also like intake assessment forms.

Physical Therapy Patient Intake Insurance Verification Form

Varieties of Physical Therapy Intake Forms

There are several varieties of physical therapy intake forms that depend on what level of therapy is provided to the client or patient, and the objective of the form. Below are some of the common varieties of this type of document that therapy centers and therapists use for their patients:

1. Physical Therapy Patient Intake Insurance Verification Form

This type of physical therapy intake form focuses on verifying the insurance claims of the patient or the therapist’s client. The form contains an area where the client will be able to disclose his primary and secondary insurance information. With this, the therapy center will know if the client has limitations regarding the maximum visitation sessions covered by the insurance company and the actual percentage which will be minimized from the client’s session payments. You may also check out career counseling forms.

2. Physical Therapy Worker’s Compensation Intake Form

This is the type of document that workers or employed clients will use in order for them to obtain their work benefits such as the insurance that their company provides. The form contains sections that are allotted for the general information of the patient or the worker, the details of the accident, health insurance information, and the patient’s current health condition. The form is also accompanied by other documents including a patient consent form, individual authorization form, and an insurance company assignment notice form. The purpose of the consent form is to assure that the patient grants a legal consent to the therapist in conducting therapy sessions for addressing his concerns, while the individual authorization form’s purpose is to enlist and determine the people who are authorized by the patient to take his medical records and other forms that are necessary for curing his medical condition. Lastly, the insurance company assignment notice form is to inform the insurance company their obligations to hand the payments directly to the therapy center on specific days for the patient’s sessions.

Physical Therapy Worker’s Compensation Intake Form

How to Complete a Physical Therapy Intake Form

Physical therapy intake forms can be completed easily with the steps below:

1. Fill in the patient information section.

This section must have the name of the patient or the client of the therapist, his date of birth, his gender, residential addresses, marital and employment information, as well as his contact information. Most intake forms also require the client to indicate his emergency contact person or representative as an assurance that the therapist will be able to inform the chosen authorized person of the client in cases of emergencies and unexpected incidents.

2. Choose from the payment options.

Therapy sessions are expensive since the client will have to pay for each schedule and day that he will be needing for his cure. With this, the client must indicate his chosen payment method whether he will be paying directly with a cash-on-hand, through a credit and debit card, or by means of his worker’s compensation and health insurance.

3. Complete the insurance information section.

If a client is relying on his insurance coverage for the therapy sessions payments, then he needs to complete this section which will cater the insurance details. The name of the insurance company, the address of the company, the client’s policy and social security number, and the name of the employer who is associated with the client’s insurance coverage.

4. Read the stated terms and conditions.

The terms are conditions center on the obligations and the responsibilities of the client to provide a payment and to attend the scheduled sessions. To indicate that the client agreed on the therapist’s center’s terms and conditions, the client must affix his signature at the space below the general agreement as well as place the date of when he signed the form.

5. Answer the patient questionnaire.

The questions focus on determining the client’s main concerns that will need the aid of a therapist. The client must rate the severity of his condition, state which part of the body is injured, and disclose how and when the condition began. Additionally, the client must also indicate the specific hour of the day when his condition becomes more evident and painful, and if the symptoms that he is experiencing are becoming any better or worsening over time. You may also see project intake forms.

Physical Therapy Pilates Patient Intake Form

6. Disclose medical history.

Acknowledging the client’s everyday routines, sleeping and eating habits, and the client’s previous medical conditions will help the therapist through the process of making a session plan for the client. A table that caters a yes/no answer from the client is also placed in this section which centers on knowing the client’s weight, pregnancy, and other medical-related issues. The client’s acquired surgeries and medications that were currently and previously taken must be informed to the therapist to assure that the activities during the session will not trigger any underlying illness. You may also like event planning intake forms.

7. Answer social history questions.

This section deals with the client’s emotional demands, family issues, and social goals. Some therapist will also include an attitude and behavior list on this section in order to determine how the client handles issues and problems. The goals of the client will also serve as a guide for the therapist in the therapy session by associating the session’s objectives to the goals which will aid in promoting and acquiring the interest of the client. You may also check out new patient intake forms.

8. Read and sign the policy financial statement.

This policy is intended as an assurance that the client is informed about the payments and other charges associated with the therapy. Along with this financial statement is a credit card authorization which is for permitting the therapist in collecting the fees directly from the account of the client prior to the day of the next sessions. Nonetheless, the authorization should only be signed if the client prefers to pay by using his credit card.

9. Sign the authorization release and receipt acknowledgment of privacy practice notice.

These two statements are significant in giving a legal permission to the therapy to acquire medical forms and related documents that can be used for the client’s therapy sessions. On the other hand, the receipt acknowledgment of privacy practice notice indicates that the client has been informed about the privacy and confidential agreement of the therapy center.

10. Read the formal letter attached to the form.

The purpose of having the letter is to put additional terms, conditions, and details about cancellation policy of the therapy center. Once the client finishes reading the letter, he must affix his signature and submit the form to the therapy center staff.

Physical Therapy Sports Patient Intake Form

What’s Included in a Physical Therapy Intake Form

One inclusion in a physical therapy intake form is a minor patient agreement form. This should be signed by the patient’s legal guardian or parents in order for the therapist to conduct the therapy sessions and acquire the right amount of payment for each session. The agreement can also include details about the therapy center’s policies, rules, and regulations regarding charges, cancellations, and session delays.

Another inclusion is a diagram where the patient or the client can indicate or encircle the areas of his body, which must be focused by the therapist. This diagram is often indicated along with the medical history and health concern sections of the form. Nonetheless, it is more effective and detailed if the client will ask supervision from the therapist or the staff in completing the diagram to assure that the right area is marked. You may also see psychotherapy intake forms.

Physical Therapy Patient Intake Form in DOC

Benefits of Using a Physical Therapy Patient Intake Form in DOC

Physical therapy intake forms come in different arrangements, varieties, and formats. One of the most common is in DOC or in word document format. Compared to other formats available, this format allows the user or the therapy center staff to reuse the logos and images that he used in the document since it is not embedded and locked. Another benefit that users can have in using a word document format intake form is that it eases up the process of checking grammars and spelling errors. There are software applications that aid a word document file to be analyzed wherein the errors are changed and marked. Lastly, the intake form in word document format is easy to edit and manage which promotes an ease of use to the users and the clients of the therapy center. You may also check out coaching intake forms.