New Patient Intake

Welcome!
Thank You for choosing Speech Language Associates

In order to serve you, with your Speech, AAC, ASL, Audiology and OT needs, in the best possible manner we will need to collect some information. This includes:
1. Patient Information
2. Case History
3. Responsible Party Information
4. Insurance Information
5. CC Information
6. Consent and Acknowledgement Forms
You will want to have the above information available when filling out this document. We are required by law to have many of these forms on file. In an effort to streamline this process we have prefilled as many of the fields as possible.

The following document is broken down into sections. Just click on the section arrow to view the questions. You can collapse the section once complete to make the document more readable.

If you have any questions regarding the forms please email admin@speechlanguageassociates.com.

Thank you again,

Kristy
This patient is a*

ChildAdult

Do you have any Occupational Therapy concerns?
Patient Intake Forms

Click on each selection below to enter information
Name of Person Completing the Forms*

First NameLast Name
Relationship to Patient
Or, "self"

Patient Information
Patient Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Primary Doctor*
Primary Group Practice Name
Other - Group Practice Name
Name and Address of Physicians Practice*

Was patient premature at birth? If yes, how many weeks?
Patient's birth weight:
Was the patient in the PICU/NICU at birth?
Does the patient have a history of tongue/lip tie?If yes, was it resolved?
Is the patient mobile?

YesNo
Age patient began crawling:
Age patient began walking:
Does the patient have any diagnosed conditions? (medical/neurological/other)If yes, explain:
Has the patient had any surgeries major or minor?If Yes, what kind?
What is the reason for an Occupational Therapy evaluation?
Has the patient had a previous Occupational Therapy evaluation? If yes, when and where?
Has the patient previously received Occupational Therapy services? If yes, please explain:
Is there anything else you would like our Occupational Therapy team to know?

Financial Responsibility Information
Please provide information on who is financially responsible for the provided services.
Name*

First NameLast Name
Phone Number
We will use this phone number for appointment reminders.
Mobile Number
We will use this phone number for appointment reminders.
Email
example@example.com
Preferred Communication Method

MobileWorkEmailText
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Information
Insurance Company
Policy Holder
Relationship to Patient
Group #
Policy Holder SSN#: _______ ____________________________
ID
Policy Holders Date of Birth

MonthDayYear
Date
Patients ID # (if available)
Copy of Insurance Card - Front

Cancelof
Copy of Insurance Card - Back

Cancelof

Payment Policy Agreement
As a courtesy, Speech Language Associates, verifies the benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. The claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of Speech Language Associates, that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment and any outstanding balance at time of service. If there is a credit, you will be provided a refund.

If the patient is covered by one of our contracted health insurance carriers and has Speech/Language benefits, we will be happy to bill your insurance. Accepting your insurance does not place all financial responsibilities onto this practice, and you are responsible for any unpaid balances by your plan. As a rule, we will bill your credit card on file for the unpaid balance 10 days after receiving the Explaination of Benefits from your carrier. We do not send automated monthly statements to request payment through mail.

Although we are contracted with several insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.

If we do not participate with your insurance carrier, you will be responsible for Speech Language Associates fees at the time of service. You may request a receipt of services to submit directly to your insurance carrier by emailing info@speechlanguageassociates.com. Speech Language Associates will provide additional information regarding services rendered upon request should your insurance carrier request more information beyond the receipt for services. It is your responsibility to contact their insurance carrier to determine the required documentation for filing insurance claims.

Failure to make any payment will result in the patient’s services being suspended until payment is received and your account is paid in full. Late fees of 1.5% per month will be charged on balances that are still unpaid starting 30 days after the first statement. There is a fee of $35 for returned checks. Delinquent accounts may be turned over to a collection agency at which time you agree to be responsible for any collections charge and all associated legal fees in addition to the amount owed.

You must notify Speech Language Associates of any change in insurance coverage or attending physician.
CANCELLATION & NO-SHOW POLICY

We strive to provide excellent care to our patients. In order to be consistent with this, we have a Patient No-Show and Cancellation Policy that we expect patients to adhere to. When an appointment is scheduled, that time has been reserved for you and when it is missed or cancelled on short notice, that time cannot be used to see another patient.

In order to avoid incurring a cancellation or no show fee, you must contact our office at 856-492-1355 at least 24 hours prior to the scheduled appointment. We will reschedule the appointment for you and leave the time open for another patient to be seen. If you miss your appointment or cancel with less than 24 hours notice, Speech Language Associates reserves the right to bill you the cancellation/no show fee of $45. This fee is the patient’s/responsible parties’ responsibility and is not billable to insurance.

Additionally, if a patient is more than ten (10) minutes late to his/her appointment, we reserve the right to cancel the appointment and the cancellation fee will apply. If the patient misses 3 or more appointments within a 6-week period, Speech Language Associates reserves the right to place your patient’s services on hold until scheduling conflicts are resolved. A consistent schedule is essential to patient progress in speech-language therapy.

We do realize that on rare occasion emergencies may arise and we will address these situations with you at that time. We thank you for working with us to ensure that services are provided to all our patients in the best possible way.

Illness

If the patient has a fever, a persistent cough, or a runny nose, please call and cancel your appointment. Speech language therapy requires the therapist be in close proximity to a patient’s face, putting them at a higher level of risk for contracting the illness and/or spreading it to other patients. As a general rule of thumb if the patient has been on an antibiotic for 24 hours and does not have a fever, is not coughing frequently, and does not have a runny nose, he/she is probably not contagious. We appreciate your understanding and will be happy to reschedule your appointment.

We do realize that on rare occasions sudden illnesses may arise and we will address these situations with you at that time. We thank you for working with us to ensure that services are provided to all our patients in the best possible way.

Inclement Weather

During times of inclement weather our primary goal is to keep our therapists and patients safe. To that end, Speech Language Associates reserves the right to cancel or reschedule appointments in the event of inclement weather. We follow the same inclement weather policy as the facility where the patient is being seen. If the facility closes at noon, we will automatically cancel all appointments after noon. If you are a private patient our office will reach out to you to inform you of cancellation and/or the option to switch to teletherapy. If a patient keeps the same appointment time each week, it is understood that they will be seen at the same time the following week.

AGREEMENT TO PAYMENT and CANCELLATION POLICIES

I have read and accept the above policies including payments, issued appointments, illness, and inclement weather.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date

Credit Card Authorization
CREDIT CARD AUTHORIZATION

i have read and agreed to the Payment and Cancellation policies of Speech Language Asscocitates. The undersigned hereby authorizes Speech Language Associates, LLC to charge the below-referenced credit card for services rendered and any related expenses.

In addition, I understand my credit card will be charged in the event that:
1. I do not pay my outstanding balance in full on the date of the visit.
2. There is a balance due after insurance benefits have been received.
3. Proper cancellation procedures are not followed as noted in the Cancellation and No Show Policy.
4. A check is returned for insufficient funds (fee of $35.00)
5. At discharge, if an account balance remains, your credit card will be charged for unpaid services to discharge date.
Credit Card Type*

VisaMastercardDiscoverAmerican Express
Name as it appears on Credit Card*
Credit Card Number   *
Expiration Date   *
Security Code   *
Billing Address on Credit Card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand and agree it is my responsibility to inform Speech Language Associates, LLC of any changes to my credit card information including address, zip code, updated expiration dates, account numbers and security codes.

BY SIGNING BELOW, I AUTHORIZE SPEECH LANGUAGE ASSOCIATES TO CHARGE THE CREDIT CARD INDICATED IN THIS AUTHROIZATION FOR UNPAID BALANCES ACCORDING TO THE TERMS OUTLINED ABOVE. I CERTIFY THAT I AM AN AUTHORIZED USER OF THIS CREDIT CARD AND WILL NOT DISPUTE THE PAYMENT WITH MY CREDIT CARD COMPANY; SO LONG AS THE TRANSACTIONS CORRESPOND WITH THE TERMS INDICATED IN THIS FORM AND/OR SPEECH LANGUAGE ASSOCIATES PAYMENT, CANCELLATION AND NO-SHOW POLICIES.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Communication Terms
Regarding the individual named above, I give permission for the therapist/Speech Language Associates to...
1. Communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via text, email and voicemail.
2. Communicate with me regarding therapy sessions (including progress, attendance, scheduling, etc.) via written note home at daycare/preschool/school. I understand that these notes will be left in my child’s backpack, cubby, folder, or wherever directed by my child’s teacher or caregiver.
3. Communicate with teachers and caregivers at my child’s school/daycare regarding therapy evaluation results/sessions in order to help carry-over skills learned in speech sessions.
4. Communicate with me via email regarding therapy. Some emails may include PDF attachments and Word documents which may or may not be password protected.
I understand that...
1. If I want my child’s therapist to communicate with anyone other than the parent/guardian of the child indicated on initial paperwork, I will sign and authorize consent to do so. I will request Speech Language Associates to do so in writing.
2. If a divorce or separation situation exists, a custody agreement and separation agreement will need to be shared with Speech Language Associates and my child’s therapist. I will share custody agreements with my therapist/Speech Language Associates so that my therapist only shares information with legal guardians of my child.
3. My child’s invoice for speech services will be emailed or mailed to me. Information containing diagnosis codes, procedure codes, dates of service, cost of service and insurance plan information will be included on these invoices.
4. If my child is seen in a daycare/preschool setting, my child will be seen where the teachers/daycare/preschool director instructs therapy to occur. This could mean that therapy may occur in a public place, such as a hallway or resource room.
5. My child’s pediatrician will be sent orders for signature, as well as plans of care and progress notes.
I accept the above communication terms,
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Permission to Treat and Terms of Service
Name of Patient*
PERMISSION TO SCREEN, EVALUATE AND/OR PROVIDE THERAPY

Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist.

I, the parent/guardian or client, authorize Speech Language Associates, to screen, evaluate and/or provide the necessary speech and/or language treatment/therapy/services to the above named individual.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
PERMISSION TO SCREEN, EVALUATE AND/OR PROVIDE THERAPY

Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist.

I, the parent/guardian or client, authorize Speech Language Associates, to screen, evaluate and/or provide the necessary speech and/or language treatment/therapy/services to the above named individual.

Consent or Release of Information
Individuals Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
CONSENT FOR RELEASE OF INFORMATION

I, or the Parent or Guardian of the aboved name individual, hereby grant Speech Language Associates permission to communicate with the following persons or agencies:
Physician
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you would like us to communicate with any other professional/person regarding the patients communication skills, i.e., physical therapist, occupational therapist, teacher, etc, please list in the box below
Name
Role
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Speech Language Associates may discuss and release to the aforementioned person or agency information including but not limited to: evaluation reports, treatment plans, progress notes and therapy documentation, previous medical history, as well as necessary verbal communication pertaining to the Patient. This information will be used for diagnostic and treatment planning purposes only. It is my understanding that this information will not be shared with any other entity without my prior knowledge.
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date

PATIENT NOTIFICATION OF PRIVACY POLICIES (HIPAA AUTHORIZATION)
PERMISSION TO SCREEN, EVALUATE AND/OR PROVIDE THERAPY

Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist.

I, the parent/guardian or client, authorize Speech Language Associates, to screen, evaluate and/or provide the necessary speech and/or language treatment/therapy/services to the above named individual.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Privacy Notice Acknowledgement
Acknowledgement That You Received Your Privacy Notice

Speech Language Associates, LLC is required by law to keep your health information safe. This information may include:
- Notes from your doctor
- Your medical history
- Your test results
- Treatment notes
- Insurance information
We are required by law to give you a copy of your privacy notice. Please retain a copy of this privacy notice for your records. This notice tells you how your health information may be used or shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have been given a copy of our privacy notice.
Signature*

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Photo/Video Consent

Speech Language Associates, LLC asks that we use your's or your child's photos/videos for our website, training purposes, social media, literature, and our clinic spaces.

If you choose to allow Speech Language Associates to use yours or your child's photos/videos, please sign below:

By signing this page, you are saying that you grant Speech Language Associates photo/video consent.
Signature

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Name

First NameLast Name
Date*

MonthDayYear
Date

COVID-19 Policy
Speech Language Associates, LLC Responsibilities:

Each clinician will be responsible to wipe downall common surfaces including toys, tables, furniture, door knobs, ipads and other therapy materials before and after each session.

Clinicians will wear cloth or disposable masks as much as able and appropriate during and after sessions. As speech therapists there may be times during session when we will need to utilize therapudic techniques that will require our face and mouth to be visable to the client. Therefore, there may be times that it will be necessary to conduct sessions without the use of a mask, however we will do our best to conduct as much of the session as possible with a face covering.

Clinicians will wear disposable gloves during sessions if necessary.

Hand sanitizer will be available to all clients before, during and after sessions.

Client Responsibilities:

Clients will wait in their cars until their therapy session time. No one will be allowed in the waiting room prior to their therapy session start time.

Clients may be accompanied by one adult to their therapy session. No siblings or other family members will be permitted to wait in the waiting room during sessions.

Clients will be asked to wash hands or use sanitizer prior to start of the session.

Clients will have the option to wear their own mask provided by parents during sessions, however, the use of a mask may be contraindicated for certain types of therapy sessions when it is nessesary for the clincian to see face/mouth. i.e. articulation therapy

No client will be allowed in the office if they or any family member has had a fever in last 48 hours.

Clients agree that they will schedule in person therapy sessions at their own discretion, understanding the risks and agree that they will not hols Speech Language Associates, LLC responsible should they become ill.

Clients will continue to provide at least 24 hours notice when cancelling any appointments or be subject to cancellation fees.

I understand that in person therapy will be scheduled at my own discrettion and clinician reserves the right to discontinue in person sessions at anytime.

I agree to all the above client responsibilities and agree to take responsibility for all risks associated with in person sessions and do not hold Speech Language Associates, LLC responsible for any illnesses my child or family may contract due to in person sessions.
Signature

Clear
Date

MonthDayYear
Date
Name

First NameLast Name

Sensory Gym Policies and Waiver
Speech Language Associates has established policies to ensure our clients have both a fun and safe experience while participating in therapy using our sensory gym. Please review the following policies. If you have any questions regarding our policies and procedures, please contact our office manager, by email or phone at admin@speechlanguageassociates.com or 856-492-1355.
- No food, drink or gum is allowed in the sensory gym.
- No shoes on the mats, with the exception of shoes needed to position orthotics.
  Siblings are not allowed on any equipment if present during evaluations or treatment.
- All children and families must be accompanied by a therapist when in the gym.
- Changing table is located in front lobby restroom for all diaper changes.
- Parents are welcome to observe their child in the sensory gym; however, we ask that they remain seated in the chairs located in the gym.
- Use of the equipment and mats are reserved for the treating child and for the therapist only.
Sensory Gym Release Waiver and Assumption of Risk

I do hereby give my consent for my child to participate in the sensory gym at Speech Language Associates, LLC. I am fully aware that engagement in activities in the sensory gym presents a risk of injury during treatment and evaluations. I am fully aware of and appreciate the risk and damages that might occur as a result of my child's participation in or attendance at SLA. Nonetheless, I, on my own behalf of my child and our heirs, administrators and executors, do hereby release, indemnify and agree to hold harmless SLA and all persons or entities associated with SLA. from any responsibility or liability for any and all claims, demands, damages, costs, causes of actions and expenses (including, without limitation, reasonable attorneys' fees) arising out of or resulting from my child's participation in or involved with any therapy/evaluations, including without limitation, any personal injury, disability or property damages incurred or sustained by me or my child during or as a result of treatments/ evaluations conducted by SLA. I understand that the participant’s family medical insurance policy must cover any medical costs incurred in case of an accident. I do hereby verify that I fully understand and accept the preceding conditions for permitting my child to participate in therapy/evaluations at SLA.
Child's Name:   First Name   Last Name
Date of Birth:     Date
Address: Street Address   Address Line 2   City   State   Zip
Date :   Date
Signature

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Welcome!

Patient Intake Forms