Children's Therapy Center Intake Packet

Children's Therapy Center Intake Packet
NEW CLIENT INFORMATION
Today's Date*

MonthDayYear
Child's Name*

First NameLast NameSuffix
Date of Birth*

MonthDayYear
Age*
Gender*
Ethnicity
Social Security Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name*

First NameLast NameSuffix
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
#2 Parent/Guardian Name

First NameLast NameSuffix
Parent/Guardian Phone Number
Please enter a valid phone number.
Siblings Name(s)/Age(s)
Please enter one per a line
Child currently lives with*

First NameLast NameSuffix
Who is legally responsible for the child? Please list relationship to the child.*
Languages spoken at home*
Any family history of speech, language, and/or hearing problems?*
Please specify
Emergency contact*

First NameLast NameSuffix
Relation to Child*
Phone Number*
Please enter a valid phone number.
What type of insurance do you have?*

MedicaidCommercialNo insurance at this time
Carrier or Company*
Medicaid Carrier*
Medicaid Member ID*
Policy Holder's Name*
Policy Holder's DOB*
Policy Number:*
Group Number*
Please upload a photo or scanned copy of your child's insurance or Medicaid cards here:

Cancelof
How did you hear about us?*

MEDICAL INFORMATION
Pediatrician Name*

First NameLast NameSuffix
Pediatrician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Medical diagnosis (if known)
Does your child take any medications? *
Please Specify
Does your child have any allergies? *
Please Specify
Is your child current on his immunizations?*
Please Specify
Has your child been exposed to any communicable diseases, such as chicken pox, measles, TB?*
Please Specify
Does your child have a history of seizures? *
Please Specify
Has your child ever been hospitalized? *
When and Why?
Does your child have any swallowing difficulties or reflux?*
Please Specify
Does your child have any limitations on physical activities? (For example, due to breathing or heart problems or other medical issues)*
Please Specify
Does your child use any adapted or specialized equipment, such as walkers, splints, hearing aids, augmentative communication devices?*
Please Specify
Has your child ever received speech, occupational, or physical therapy? *
Please describe which therapy, when, and where
Has your child had a hearing test?*
When? What were the Results?
Has your child had a vision test?*
When? What were the Results?
Do you have any other concerns about hearing or vision?*
What are your concerns?

PREGNANCY / DEVELOPMENTAL HISTORY
Was pregnancy uneventful? *
Please describe any medical issues, injuries, etc that occurred during pregnancy.
Length of pregnancy
Caesarean delivery?
Birth Weight
Difficulty breathing/heart problems/jaundice?
Please describe and what interventions were taken (i.e.: oxygen, NICU, incubator, etc.)
Any other pertinent information about your child’s birth history? *
Age at which he/she
Babbled
Responded to Name
Said single words
Used 2-word combinations
Followed simple commands
Used sentences
Rolled over
Sat unsupported
Crawled
Pulled to stand
Walked alone
Potty Trained

EDUCATIONAL HISTORY
Does your child attend school? *
Where?
Does your child attend daycare?*
Where?
Does your child have an IFSP/IEP? *
Please Specify
Is there anything else about his/her daycare/school performance that you would like us to know?

GROSS MOTOR OBERSERVATIONS
Is your child safe and independent on stairs?*
Is your child safe and independent on playground equipment?*
Does your child pedal and steer a tricycle/bicycle with training wheels/2-wheeled bicycle?*
Please Specify
Does your child throw a ball in a controlled manner/catch a small ball with his hands/kick a ball that is rolling toward him? *
Please Describe
Does your child run in a manner and speed similar to other children the same age? *
Please Explain
Has your child or does your child currently participate in any community sports programs such as swim lessons, dance, gymnastics, soccer, karate?*
Please Describe

ADDITIONAL INFORMATION
What services are you requesting for your child?

Occupational TherapyPhysical TherapySpeech Therapy
What concerns/questions do you have about your child’s speech, language, gross, or fine motor development?
Is there anything else you would like us to know about your child?

AUTHORIZATION FOR TREATMENT
I hereby request and give my permission for the therapists of Easter Seals Southwest Florida to provide such medical examination and treatment as they deem best for the child. I voluntarily consent to therapy as determined to be necessary or beneficial in the professional judgment of my physician or therapist. I acknowledge that no guarantees have been made to me as to the affect of such treatment on my condition.

As client, parent, or legal guardian, I give my full consent to Easter Seals Southwest Florida’s clinical staff to provide medical examination and treatment for my child. I will submit a signed notification to the Easter Seals Southwest Florida Children’s Therapy Center of any change in the above information or permission.

I direct my insurer and third parties to pay directly to Easter Seals Southwest Florida any insurance benefits due for services on behalf of the patient. I hereby assign Easter Seals Southwest Florida all my rights to receive payments from my insurer and third parties for services rendered by Easter Seals Southwest Florida. As stated in the note on the front page of this packet, I understand that I am responsible for copayments and charges for non-covered services. I agree to accept full responsibility for all charges due upon receipt of statement.

Easter Seals Southwest Florida accepts cash, checks, and all major credit cards. Checks returned for insufficient funds (NSF) will be assessed a $25 returned check charge unless payment in cash is received within 48 hours following NSF notification. I understand I am responsible for any costs incurred in the collection of the patient’s account in case of default, including reasonable fees. Easter Seals Southwest Florida has a Financial Counselor available if needed to discuss any benefits or billing questions and/or to plan for your financial responsibilities.

I agree that medical information regarding my child’s diagnosis and treatment may be released to the natural mother, natural father, stepmother/father, referring physician, and other physicians involved in the care of my child, and to the insurance company. Restrictions must be submitted in writing to our Privacy Officer.
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
In the event of my absence, I, as parent or legal guardian of*

First NameLast NameSuffix
give my permission to Easter Seals Southwest Florida to seek emergency medical treatment for my child.
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear

HOLD, CANCELLATION & DISCHARGE POLICY
In order to ensure efficient use of our therapists' schedules and to maintain a healthy environment, we have implemented the following policies:

1. Arrive on time for your scheduled appointment.
2. Call as far in advance as possible. Our phone number is (941) 355 - 7637 x482.
3. No “No Show” without a doctor’s note brought to the next visit.
4. One cancellation allowed per month
5. If you are 15 minutes late to an appointment, it is up to the therapist whether or not to see your child, and if they are seen this appointment will count as a cancel.
6. If these policies are violated, your child will be discharged from therapy and placed on a waiting list.

Please sign below to acknowledge that you have read and understand the above policies:
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear

PHOTO RELEASE FOR MINORS
In exchange for consideration received, I hereby give Easter Seals Southwest Florida, Inc. the unrestricted right and permission to copyright, use, reuse, and publish photographic likenesses of
Name of Child

First NameLast NameSuffix
in all forms and media. I waive the right to inspect or approve the finished photograph or public relations copy of printed matter that may be used. I declare that I am at least 18 years of age and am the parent/legal guardian of the subject of this release, and give my consent. I understand that the photographs will only be used to promote the purposes of Easter Seals Southwest Florida, Inc.

I hereby release, discharge and agree to save harmless Easter Seals Southwest Florida, Inc., its successors or assigns, and all persons functioning under its permission or authority, from any liability by virtue of any blurring, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of the photographs or in any subsequent processing, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

I have read and understand this photograph release prior to its execution and I fully understand the contents of this photograph release. This agreement shall be binding upon me and my heirs, legal representatives and assigns for a period of three years from the date below:
Parent/Guardian Signature

Clear
Today's Date

MonthDayYear

FINANCIAL RESPONSIBILITY AGREEMENT
Client Name*

First NameLast NameSuffix
Today's Date*

MonthDayYear
Assignment of Benefits

I hereby assign to Easter Seals Southwest Florida any insurance or other third-party benefits available for services provided to me/my dependent. I understand that Easter Seals Southwest Florida has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to Easter Seals Southwest Florida, I agree to forward to Easter Seals Southwest Florida all health insurance and other third-party payment that I receive for services rendered to me/my dependent immediately upon receipt.

*If you receive a check from your insurance company for therapy services given by Easter Seals, please bring it to our office as soon as possible. *

Insurance Coverage Waiver
I understand that my eligibility for coverage by *
(name of insurance company)
cannot be confirmed at this time. I wish to receive/I wish my dependent to receive services from Easter Seals Southwest Florida. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment for all services provided to me/my dependent.

Financial Responsibility Statement

I wish to receive/I wish my dependent to receive services from Easter Seals SW FL Children’s Therapy. I understand and agree that I am responsible for all eligible charges, including copayments, coinsurance and deductibles, as well as charges for services not covered by my insurance company or other benefit program for services provided to me/my dependent. I understand and agree to make payment in accordance with the payment policies established by Easter Seals Affiliate.
ALTHOUGH YOUR CHILD MAY QUALIFY FOR THE STATE TO PAY FOR THERAPY SERVICES…

WE MUST BILL A FAMILY’S PRIMARY INSURANCE COMPANY FIRST BEFORE THE STATE COVER THE COST. ONLY AFTER WE BILL YOUR INSURANCE COMPANIES AND GET A DENIAL WILL THE STATE REIMBURSE US. AS THE PROVIDER, WE SEND THESE DENIALS FROM THE INSURANCE COMPANY TO THE STATE AS PROOF THAT THE INSURANCE COMPANY WAS BILLED AND DID NOT PAY THE CLAIM(S). ONLY AFTER THIS PROCESS WILL STATE REIMBURSE THE COST.

PLEASE NOTE: IT IS THE PARENT/GUARDIANS RESPONSIBILITY TO MAINTAIN INSURANCE COVERAGE. ANY LAPSE IN COVERAGE WILL BE THE PARENT’S/GUARDIAN’S FINANCIAL RESPONSIBILITY. ANY UNPAID OUTSTANDING THERAPY BILL OVER 120 DAYS AFTER THE SERVICE WAS PROVIDED WILL BE FORWARDED TO A COLLECTIONS AGENCY. WE DO HAVE PAYMENT PLAN OPTIONS FOR FAMILIES. IF THE BILL REMAINS UNPAID AFTER 120 DAYS, WE RESERVE THE RIGHT TO DISCONTINUE THERAPY SERVICES DUE TO NON-PAYMENT FOR SERVICES RENDERED.

**IF YOU ARE RECEIVING SERVICES THROUGH EARLY STEPS, WE WILL BILL YOUR PRIMARY INSURANCE FIRST AND THEN WE WILL BE EARLY STEPS FOR THE REMAINDER OF WHAT MAY NOT BE COVERED.**

I understand that this form, or copy thereof, is valid for twelve (12) months from the date of this agreement.
Client/Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear

PARENT CONTRACT
It is our goal to make your child’s therapy and developmental journey an enjoyable experience. We strongly believe that parents are experts when it comes to their children and therapists are specialists and facilitators. We are committed to empowering and supporting parents with the necessary information and skills to assist with their child’s development. Below please find the roles and expectations of parent and clinician.

Parent Commitment:

1. Cancel appointment 24 hours before the scheduled appointment time if unable to participate.

2. Arrive to scheduled sessions on time and attend on a consistent schedule.

3. Cancel appointment if child or other family member has a fever of 101 degrees or higher, or exhibiting other symptoms of illness.

4. Be prepared to participate and learn with child during the appointment

5. Be prepared to participate with a home program.

6. Take responsibility for other children brought to the center and follow the safety rules.

7. Refrain from using cell phones during child’s appointment.

8. Share information about child with clinician that may benefit the child’s progress and/or participation.

9. Communicate expectations openly with clinician.

10. Please bring appropriate baby items to center. i.e.: diapers, wipes, etc.

Therapist or Early Interventionist Commitment:

11. Cancel appointment within 24 hours if unable to participate.

12. Cancel appointment if I have a fever of 101 degrees or higher, or exhibiting other symptoms of illness.

13. Be prepared to develop and teach parent strategies to meet the goals identified on child’s Plan of Care.

14. Provide information about resources and new techniques that may benefit child.

15. Begin and end sessions on time.

16. Involve parent in therapy process.

17. Provide ongoing communication about child’s participation, progress, or challenges.

18. Provide home program to the parent/caregiver.

Our goal is to provide the child and family with a comfortable and supportive environment. In the event that a parent or therapist has a concern that has not been effectively resolved, the Clinical Director may be contacted at 355-7637 x421. Parents will also receive frequent surveys to monitor and improve our services.

Please note that two or more “no shows” (no call to cancel appointment) in one month, will result with the child being placed on hold until parent can resume a consistent therapy schedule.
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear

ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Easter Seals Southwest Florida is committed to protecting medical information all and is required by law to:
- Make sure all medical information is protected;
- Give you this Notice describing our legal duties and privacy practices with respect to medical information; and
- Follow the terms of the Notice that is currently in effect.
I consent to the use and/or disclosure of my dependent’s protected health information by Easter Seals Southwest Florida for the purpose of diagnosing or providing treatment, obtaining payment for health care bills, or to conduct health care operations. I understand that diagnosis or treatment services provided to my dependent by Easter Seals Southwest Florida clinical staff may be conditioned by my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my dependent’s protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Easter Seals Southwest Florida is not required to agree to the restrictions that I may request. However, if Easter Seals Southwest Florida agrees to a restriction that I request, the restriction is binding, except where medical information disclosure is required by Federal or State law.

I have the right to revoke this consent, in writing, at any time. Easter Seals Southwest Florida requires a dated and signed request along with notification of the duration of the request.

“Protected Health Information” (PHI) means health information, including demographic information, collected from me and created or received by physicians, another health care provider, a health plan, my employer or a health care clearinghouse. This PHI related to past, present, or future physical or mental health or condition and identifies my dependent, or there is a reasonable basis to believe the information may identify me/my dependent.

The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in treatment, payment of bills, or in the performance of health care operations of Easter Seals Southwest Florida.

I acknowledge I have received a copy of the Notice of Privacy Practices.
Parent/Guardian Signature*

Clear
Printed Name of Parent/Guardian*

First NameLast NameSuffix
Today's Date*

MonthDayYear

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Under federal law, patient health information is protected and confidential. Patient health information includes information about symptoms, test results, diagnosis, treatment, related medical data, payment, billing, and insurance information.

PLEASE REVIEW IT CAREFULLY

Allowed Uses and Disclosures of Medical Information:
- Treatment – such as ordering diagnostic tests, other health care providers (ex: PCP,) Pharmacy, etc.
- Payment – such as submitting billing information to your insurance company, disclosures to consumer reporting agencies (limited to specified identifying information about the individual, his or her payment history, and identifying information about the covered entity.)
- Health Care Operations – such as quality assurance review, coordination of care, and eligibility verification.
- Public Health Activities – such as child abuse or neglect.
You have a right to:
- Request restriction on uses and disclosures about treatment, payment or healthcare operations, however, we are not required to agree to any restriction. Restrictions must be submitted in writing to our Privacy Office or designee indicating (1) what information you want restricted; (2) whether you want to limit our use; (3) to whom you want the limits to apply.
- Receive confidential communications from us, upon written request.
- Inspect and request copies of your medical information.
- Request to amend incorrect or incomplete medical information.
- Receive an accounting of any disclosures made, upon written request.
- Receive a paper copy of the notice upon request or review our entire policy.
We are required to:
- Maintain the privacy of all clients’ medical information.
- Provide you with this notice and obtain written acknowledgement.
- Abide by the terms of this notice.
- Provide written notice of any change to this notice.
- Report information to federal, state, and local agencies when it is required by law.
Complaints:

You may complain to us or to the Health & Human Services secretary if you believe that your privacy has been violated. If you wish to file a complaint with us, please provide the office manager with written notice of how you believe we violated your privacy. All notices received will be investigated and reviewed by the Privacy Officer or designee. Easter Seals Southwest Florida encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against for filing a complaint.

Authorizations:

Upon your written authorization, we may disclose your medical information to a requesting entity. You may revoke any authorization you make at any time, except to the extent that it was already relied on.

Patient Contact:

We need to contact you to provide test results, appointment reminders, treatment information, or for patient satisfaction surveys. Our appointment reminders are done by telephone. If you wish to request alternative or confidential communication, please contact our Clinical Manager.

To obtain information, contact: Privacy Officer or designee at:

Easter Seals Southwest Florida
350 Braden Avenue
Sarasota, FL 34243
Please verify that you are human*
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Children's Therapy Center Intake Packet

NEW CLIENT INFORMATION

MEDICAL INFORMATION

PREGNANCY / DEVELOPMENTAL HISTORY

EDUCATIONAL HISTORY

SPEECH / LANGUAGE OBSERVATIONS

BEHAVORIAL OBSERVATIONS

GROSS MOTOR OBERSERVATIONS

ADDITIONAL INFORMATION

AUTHORIZATION FOR TREATMENT

HOLD, CANCELLATION & DISCHARGE POLICY

PHOTO RELEASE FOR MINORS

AUTHORIZATION TO RELEASE RECORDS

FINANCIAL RESPONSIBILITY AGREEMENT

PARENT CONTRACT

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES