Basic Information *
Full Name
Date of Birth
Gender
Male
Female
Other / Prefer not to say
Parent / Guardian Name (if client is under 18)
Relationship to Client
Mother
Father
Guardian
Other
Contact Number (WhatsApp preferred)
Email
Permanent Address
Postal Address / Code
Appointment Details*
Appointment Details
In-Clinic
Home-Based
School-Based
Online
Preferred Date for Appointment
Preferred Time for Appointment
Have you visited Welsh Therapy before?
If Yes, mention previous therapist/service used
Choose Service
Home & Online Therapy
Occupational Therapy
Speech & Language Therapy
Physical Therapy
Behavioral Therapy
Early Intervention Program (Ages 0–5)
Group Therapy & Social Skills Programs
Psychological Counselling & Mental Health Support
Assessment & Diagnostic Services
ABA Therapy
Educational Therapy & Learning Support
Assistive Technology & Augmentative Communication (AAC)
Therapy Type / Concern*
Therapy Type / Concern
Choose Therapy Type / Concern
Occupational Therapy
Speech & Language Therapy
Behavioral Therapy
Physical Therapy (DPT)
Psychological Counselling
Assessment / Diagnostic Services
Early Intervention (0–5 Years)
Group Therapy / Social Skills
Educational Therapy
Assistive Technology (AAC)
Other
If other, (Please Specify) Therapy Type / Concern
Primary Concern / Reason for Appointment
When did you first notice the issue?
Any previous therapy/diagnosis?
If yes, please describe
Medical & Developmental History*
Any known medical conditions?
If yes, please describe
Any medication currently being taken?
If yes, mention medication names
Any history of surgeries or injuries?
If yes, please describe
Allergies
Pregnancy / Birth History (if child client)
Normal
C-section
Complicated
Family & School Information (if applicable)*
School Name / Grade:
Teacher / Counselor Feedback (if available)
Siblings (name & age)
Therapy Goals*
What are your main goals from therapy?
How did you hear about Welsh Therapy?
Social Media
Doctor Referral
Friend / Family
School
Other
Upload Documents (Optional)
Upload CNIC / Birth Certificate
Upload Medical / Diagnostic Reports
Upload Doctor Referral (if any)
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB, Max. files: 5.
Consent & Declaration*
