Client Intake Form WE’RE HERE TO HELP YOUR CHILD! Step 1 of 17 5% Patient First Name*Patient Last Name*DOB* Date Format: MM slash DD slash YYYY Gender*MaleFemaleAddress 1*Address 2City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*How did you hear about us? Please provide names and the best possible phone number(s) and email. Be sure to notify us immediately of any changes.Parent/Legal Guardian 1*Email* Phone*Parent/Legal Guardian 2*Email* Phone* Please list anyone who may bring your child to therapy. Name*Relationship*Phone*Name*Relationship*Phone*Contact Name*Relationship*Phone*Pediatrician*Allergies Primary Insurance*Policy Number*Group Number* Current School*Grade*Please describe past Speech Therapy or Occupational Therapy services received.* Is patient a child?* Yes No Did you experience any complications, illnesses or stress during the pregnancy? (If yes please explain)If pre-term, number of weeks and birth weight?Was the patient born full term or pre-term?Pre-TermFull-TermPlease list all surgeries and hospitalizations the patients had as an infant. Medical HistoryHealth Conditions Autism Asthma Bed Wetting At Night Behavior Problems Birth Of Congenital Malformation Chicken Pox Chronic Diarrhea Constipation Drooling Eczema Emotional Problems Fluid In Ears/Ear Infection Frequent Headaches Hearing Loss Heart Disease High Fevers Meningitis Multiple Ear Infections Nervous Tics Of Tourettes Poisoning Seizures Sleeping Problems Tonsils/Adenoid Problems Upper Respiratory Infections Urinary Tract Infections Wetting During The Day Vision Problems Other Please list any developmental delays. Therapy* Speech Therapy Occupational Therapy Please check off which difficulties your child has. Articulation Executive Function Expressive Language Fluency Receptive Language Social Skills Tongue Thrust Vocal Harshness What is your primary concern today? (please be as detailed as possible)*Please check if your child has difficulty with the following functional skills: Self Feeding Use Utensils Age Appropriately Open Containers Open Chip Bags/snacks Open Water Bottle Toileting Clothing Management Sitting On The Toilet Wiping Dressing Zipping A Coat/jacket Including Latching Buttoning A Shirt Buttoning A Pants Tying A Shoe Orienting Clothing Including Socks Snapping Snaps What is your primary concern today? (please be as detailed as possible)*Check all that apply to your child: Have difficulty sitting in a chair without slouching or showing signs of fatigue. Poor balance or decreased spatial awareness/seems clumsy. Has difficulty keeping up with peers at recess/on the playground. Difficulty crossing over midline. Avoids playing on playground or participating in team sports. Difficulty manipulating small objects in hand. Poor grasp/pushes to hard on pencil/has an awkward grasp. Complains of hand pain when writing. Difficulty using scissors. Difficulty copying simple shapes and lines. Difficulty with letter formation (size, alignment and spacing of letters). Often reverses letters or numbers. Difficulty with color, letter or shape recognition. Overly sensitive to sound and visual stimuli. Overly sensitive to touch (how things feel against skin - clothes dirt, water, tags) Picky eater, only likes certain tastes or textures. Decreased attention span. Poor organizational skills. Constantly fidgeting and has a difficult time sitting still. Difficulty tolerating routine change or transitions from activity to activity. Enjoys crashing and has no awareness of safety. Doesn't understand person space and boundaries. In an attempt to provide the best service possible, any schedule changes need to be discussed at the end of the session and/or with the front desk administrator. We understand occasional changes may be necessary due to illness, vacations, etc. All cancellations must be made 24 hours in advance. Cancellations for Sunday or Monday need to be made on the Friday preceding that. We often have patients waiting to be accommodated into cancellation slots, so timely notice is of essence. If a therapy session is not canceled in a timely fashioned as outlined above, or if a session is missed with no notice at all, The Therapy Place will charge you a $50 no-show fee. Please note that insurances do not reimburse for no-show sessions; it is solely the responsibility of the parent or guardian. Two consecutive no-shows will cause your child’s slot to be put on hold until the matter is resolved. If the issue is not resolved within five business days, your child will forfeit his preferred slot. Weekends and late afternoon appointments are prime slots. If you miss two such slots (even with proper notice), we reserve the right to give away the slot. Please complete the enclosed Credit Card Authorization Form for us to have on file. Your credit card will only be charged in the event that your child misses his/her session and we have not received 24-hour notice. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. Credit card* This credit card can be used for my copay/deductible Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Amount to Charge* Price: $50.00 I authorize the Therapy Place to charge the $50 to the credit card provided in the event of a no-show or in the event of a cancellation without 24-hour notice. I agree to pay for this purchase in accordance with the cardholder agreement. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. You Are Responsible For Payment You or your guarantor is responsible for payment for services provided by us at the time the medical services are provided. You further agree that you will be responsible for payment for disclosed non-covered services. You agree that if payment in full is not received from your insurance carrier or from your personal funds, and if a lawsuit or action is brought to collect this account or any portion of it, that you agree to pay the costs of collection, including but not limited to, taxable and nontaxable costs and disbursements provided by statute as well as attorneys’ fees amounting to one-third of the total outstanding balance. Health Insurance If payment for the services that we provide for you may be covered by insurance, we will provide you with a copy of your bill at each visit which contains all the information necessary for you to bill your insurance carrier. We are required by law to submit the bill to your insurance carrier if the service provided is a covered service under your insurance plan. If we do this, it is still your responsibility to pay for any and all medical services provided to you and to request payment from your insurance carrier. If we have given you an estimate on the payment that your insurance carrier will pay, please understand that this is only an estimate and not a guarantee of payment by your insurance carrier. When an insurance carrier gives us “authorization” it is only a determination by the insurance carrier that your policy provides coverage in general for the services that are to be provided. There may be additional reasons why your insurance carrier will not, ultimately, pay for the services that are provided. You agree that regardless of what your insurance carrier ultimately pays, you are responsible for payment for the services. Minors If you are under the age of 18 at the time services are provided, your parent’s or legal guardian’s signature below constitutes an agreement and guarantee by your parent or legal guardian that they and you are responsible for paying for any and all fees. Your parent’s or legal guardian’s signature also is an acknowledgment that the services provided are “necessary” expenses. Returned Checks Returned checks are subject to a $25.00 returned check fee. Authorization for Treatment I hereby consent to and authorize The Therapy Place, PC, to perform occupational therapy treatment, under the direction and supervision of a licensed occupational therapist, necessary for the above named patient that The Therapy Place, PC or the patient’s physician advises to be necessary. I understand and am informed that, as in the practice of medicine, there may be some risks associated with the provision of occupational therapy. I understand that I have the right to ask about those risks and to have any questions about my child’s condition answered prior to treatment. I acknowledge and agree that either a parent or legal guardian will be present during each treatment session. I have carefully read and I fully understand this Informed Consent Form. I furthermore had the opportunity to discuss this Form with the treating occupational therapist. I understand that patients’ protected health information may be used and disclosed for treatment, payment, or healthcare operations purposes. For a more complete description of the potential uses and disclosures of protected health information, please refer to the Notice of Privacy Practices issued on the first day of treatment. You have the right to review the Notice prior to signing this Consent Form. To obtain additional copies of the Notice, please contact our office at 732-813-4263 I acknowledge that I have read agree to all of the information stated above. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. I understand that I am financially responsible for all services rendered whether or not paid for by insurance. If a referral form is required by my insurance company for a service and I neglect to secure it, I am financially responsible for the service provided. I hereby authorize the release of medical information deemed necessary by The Therapy Place, PC. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. I authorize The Therapy Place to communicate with my child's school regarding my child's therapy. I authorize the following: * Release Of Occupational/speech Therapy Records Verbal And Written Communication With Teachers And Staff I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective when The Therapy Place has already relied on the authorization for the use or disclosure of my health information or if my authorization was obtained as a condition of my obtaining insurance coverage and the insurer has a legal right to contest a claim. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. I authorize the release of any medical information necessary to process my claims. This authorization remains valid until I give written notice that it is explicitly revoked. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. I grant permission for my child, if enrolled, to be included in school photographs and give the school permission to use these photographs on parent night, in school displays, in school brochures, on school websites password protected, and in slideshows shown externally. * I have read and agree to the "Photo Agreement" statement. (required) I allow students to observe my child's therapist during treatment. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. I hereby authorize The Therapy Place to send me appointment reminders as well as other communications via e-mail or text message using the following information. Email reminders may contain patient or clinic information such as, but not limited to, patient first name and clinic location. Sign by typing your name*Signature* I am a parent or legal guardian of the patient. Your electronic signature is the online equivalent of your ink-on-paper signature, and can be provided by typing your name where indicated. The electronic signature will signify your understanding, acceptance, and authorization of the conditions of this legal document. You must be 18 years of age to legally sign this online waiver. If you are under 18 years old have your parent or legal guardian sign the waiver. * I agree to the HIPAA Privacy Statement
