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Client Intake Process - Therapy Services

Car-ynne 4 Kids organization is dedicated to supporting and empowering our community through various programs and initiatives. Our mission is to make a positive impact and create a better future for all.

Complete Intake Form HERE

Client Intake Form

Thank you for inquiring about receiving services from Car-ynne 4 Kids. If you are interested in getting information or would like to have your client be put on our waitlist, please fill out the form.

If you have questions regarding billing or insurance, please refer to the FAQs located under the 'About' tab.

Please complete the form below.

Client Name*

Primary Diagnosis*

Mobility Status (ambulatory, walker, manual w/c, power w/c)*

Height*

Weight*

Date of Birth*

Payor Source (Private Insurance, Medicaid, Private Pay)*

Preferred Availability (specific day/time, after school, weekends)*

Is client currently receiving any other therapies? Intensives, etc.*

Parent/Responsible Party Name*

Parent/Responsible Party Email*

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