Intake Form

Referrals are simple:
Simply fill out this online form or click on the download form to fill out and email/fax it to our office.

Email: office@backhometherapy.com
Fax: (443) 450-4282

First Name*

Last Name*

E-MAIL*

Gender*

Date of Birth*

Address*

City, State, Zip*

Home Phone Number*

Cell Phone Number

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Primary Care Physician's Name*

Primary Care Physician's Phone Number*

How Did You Hear About Us?*

Primary Insurance Name*

Primary Insurance ID #*

Secondary Insurance Name (or N/A) *

Secondary Insurance ID # (or N/A) *

What is the Diagnosis?

Additional Comments

Note: A Doctor's Order for PT/OT services is required before services can begin. Please have your doctor fax it to our office at 443-450-4282 or upload. Thank you.

(410) 415-3743

office@backhometherapy.com

Intake Form