402-933-2882 info@zierinstitute.com

NEW PATIENT FORMS

Understanding the Unique Needs of Your Child

Want to schedule an appointment? We look forward to hearing you. For all new patients, we require the Parent Pack Intake (below) to be filled out and submitted prior to your child’s first appointment. For adult patients, select group attendees and non-therapeutic clients fill out the Patient Intake (below). For your convenience you can fill the forms out online.

PARENT PACK INTAKE

Policies, background Information for new patients.

SENSORY QUESTIONNAIRE

Help us understand your child’s profile.

PATIENT INTAKE

Simple intake forms for adult patients, select group attendees and non-therapeutic clients.

FEEDING THERAPY INTAKE

Additional intake form for feeding therapy clients. This service may be held virtually with our Chicago clinic.

Questions? Contact us today.