Intake Page - Advanced Speech & Language Therapy

Client's Name

First Last

Phone

Date of Birth

MM

DD

YYYY

Age

Address

Street Address City State / Province / Region ZIP / Postal Code

Father's Name

First Last

Address (if different from child)

Street Address City State / Province / Region ZIP / Postal Code

Preferred phone number

Cell Phone

Email

Employer

Occupation

Business Address

Business Phone

Mother's Name

First Last

Address (if different from child's)

Street Address City State / Province / Region ZIP / Postal Code

Preferred phone number

Cell Phone

Email

Employer

Occupation

Business Address

Business Phone

Contact email address

Referred by

Reason for referral

Pediatrician

Phone

Who is financially responsible for this bill?

* Email address where you would like a copy of this form sent

Enter Email Confirm Email

Child's Case History

Describe any concerns that caused you to refer your child.

Has anyone made a diagnosis of the problem or cause?

If so, what was that diagnosis, when was it made, and who made it?

Describe any current medical conditions that you feel may be related to the problems your child may be experiencing.

Has your child ever had their hearing tested?

Does your child have a history of ear infections?

If so, please indicate how many and the type of treatment received.

Does your child have any food allergies?

If so, please indicate type and severity.

Please list any medications your child is currently taking.

Is there a history of any kind of learning problems in the family?

If yes, please indicate relation and type of difficulty.

Birth History:

Briefly describe your child's birth history including pregnancy, labor and delivery.

Developmental Milestones

At approximately what age did your child:

Sit without assistance:

Crawl:

Walk:

Say his/her first words:

School

Is your child attending school?

If yes, please provide the name of the school, as well as days/times.

Therapies

Is your child receiving or has received any other therapies (i.e., occupational therapy, physical therapy)?

If yes, please indicate the provider and reason for therapy

Please provide any other information you feel might be important for us to know.

Agreement to Terms of Payment

I acknowledge and accept full and complete responsibility for payment of all services rendered to me by Robyn Gould/Jenny Lind/Advanced Speech & Language Therapy, LLC. I understand that health and accident insurance policies are an arrangement between my insurance company and me and that services rendered me are charged directly to me, and that I am personally responsible for payment. I agree to allow Robyn Gould/Jenny Lind/Advanced Speech & Language Therapy to release any information that is requested by my insurance company. My initials serve as my legal signature.*

please initial above

I understand that I am obligated to pay Advanced Speech & Language Therapy, LLC for all services we render to me or my child. My initials serve as my legal signature and by signing, I authorize you to charge my credit card for your professional services.*

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Today's Date

Release of Information

No information concerning the child or the evaluation results will be released unless the following form is signed by the parent or legal guardian. Signature is required for reports to be provided for anyone either than parent or legal guardian. Your initials represent your legal signature.

I authorize Robyn Gould/Jenny Lind/Advanced Speech & Language Therapy to release information concerning the above to other professionals, agencies, or designated recipients. My initials serve as my legal signature.*

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Policies and Procedures

Thank you for allowing us to be your healthcare provider. Our office is committed to the success of your child's treatment. The following is a statement of financial policy. Please read, type your initials to indicate your agreement with each of our policies. Your initials represent your legal signature.

1. If you must cancel a scheduled appointment, it is necessary that you cancel 24 hours in advance of the appointment. Except in cases of emergency or sudden illness, appointments not cancelled 24 hours before will be charged as though the session were held. Please type your initials to indicate that you agree with this policy.*

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2. Although payment is the client's responsibility, we will provide assistance with insurance claims at your request including dates of intervention, diagnosis, and/or progress reports. Please allow 2 weeks for our office to prepare the information required by your insurance company. Please type your initials to indicate that you agree with this policy.*

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3. Unless otherwise arranged, statements for service are sent at the end of every month for the number of sessions scheduled during the month. Please type your initials to indicate that you agree with this policy.*

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4. Each payment for evaluation and intervention is to be made directly to Advanced Speech & Language Therapy each month, even if insurance coverage is arranged. (The insurance company reimburses the individual and not the speech clinician.) Please type your initials to indicate that you agree with this policy.*

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5. Fees for intervention are billed at the rate of $170.00 per hour session, and $85.00 per half hour session. Evaluations are $250 for articulation assessment and $400 for a language assessment. This includes a written report. Please type your initials to indicate that you agree with this policy.*

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6. Bills that remain unpaid for 1 month following receipt of statement for services will be subject to an additional 5% charge on the unpaid balance. Please type your initials to indicate that you agree with this policy.*

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New Client Information

Child's Case History

Birth History:

Developmental Milestones

School

Therapies

Agreement to Terms of Payment

Release of Information

Policies and Procedures