Speech Client Intake Form

Speech Client Intake Form
Today's Date

MonthDayYear
Date
Client Name*

First NameLast Name
Client Date of Birth:*
Age:*
Gender:*
Preferred location for services (New - Elmwood location is 524 Elmwood Park Blvd. or Metairie Location is 3329 Metairie Road):
Has your child had a Speech/Language evaluation completed within the past year?

YES (if so, we will need a copy of the report)NO
Parent Name*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*

Area CodePhone Number
Home Phone number:

Area CodePhone Number
Email*
example@example.com
Child's primary care physician:*
Phone Number:*

Area CodePhone Number
Emergency contact:*

First NameLast Name
Phone number:*

Area CodePhone Number
Relationship with Client:*
Email:*
example@example.com
Diagnosis (Please indicate any medical diagnosis or medical condition below):*
Why is this speech evaluation being requested?*
What is your availability for the initial evaluation and weekly sessions? Our clinic is open 9 AM - 6 PM and our therapists see clients Mondays - Thursdays.*
Will your child be attending any of TLC's day programs?

Building BlocksConnect Kidsnone
If they will be attending Building Blocks or Connect Kids, what is their start date for the program and how often will they be attending?
How did you hear about TLC?*
What days/times are you available for an evaluation?

	Approximate age
Sat alone
Crawled
Walked
Toilet trained
Grasped crayon/pencil
Began to scribble/draw
Babbled
Said first words
Put two words together
Spoke in short sentences

	Approximate age
Babbled
Said first words
Put two words together
Spoke in short sentences

Guarantor Information
Guarantor:*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Relationship with client:*
Social security number:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:*
Insurance Information
Name of Insured:

First NameLast Name
Date of birth:*

MonthDayYear
Date
Social Security Number:
Employer:
Health Insurance (We are not in network with Medicaid.)*
Policy/Member ID#:
Provider Service#:

Area CodePhone Number
Group#:
Please upload a copy of the front and back of your insurance card.

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Insurance Card Cancelof
Please upload a copy of your driver's license.

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Driver's License Cancelof
Speech Referral and Hearing Screening
Do you have a referral for speech therapy services from a doctor? (YES/NO)*
If yes, please upload a copy of the prescription for Speech Therapy services. (We will need this document to schedule an evaluation. The pediatrician can write a prescription for speech services as long as the child has attended their most recent annual appointment.)

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Prescription Cancelof
Has your child had a hearing screening completed in the past year? (if no, you will need to schedule a hearing screening to be completed before we can schedule an evaluation)

YesNo
Has your child had a hearing screening completed in the past year? (if your child is under the age of 3, you will need to submit a hearing screening before we can schedule an evaluation)*
Please upload a copy of hearing evaluation within the last year.

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Hearing Results Cancelof

Please upload a copy of your driver's license.

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Driver's License Cancelof
Consent
I hereby give Therapeutic Learning Center, LLC permission to evaluate and treat my child, and I understand there will be written, oral, and electronic communication between care providers/physicians and insurance companies. Certification or licensing and quality assurance may review my child's records. I understand that all practices of confidentiality will be followed within use of the information gathered.*
I have checked with my insurance company prior to this therapy visit and assert that I have obtained the necessary information regarding limits of coverage, co-pays and co-insurance.*
I give Therapeutic learning Center, LLC permission to submit bills directly to the insurance carrier.*
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures and/or webspace:*
Permission Slip, Indemnification, Medical Agreement, and Grant of Rights
I hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Clinic ("clinic"). I understand that the clinic is completely voluntary. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this clinic. I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the clinic.

If any emergency medical procedures or treatments are required during the clinic, I hereby consent to the staff of TLC’s clinic, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter.

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

The Undersigned expressly agrees that the foregoing Release, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.
I have read and agree to follow Therapeutic Learning Center, LLC Permission Slip, Indemnification, Medical Agreement, and Grant of Rights.*
Signature*

Clear
Payment and Attendance Policies

Please read carefully and initial to indicate you understand and agree to each policy
CANCELLATION FEES
- I understand that I will be charged a LATE CANCELLATION/No-Show fee of $75 if I fail to give at least 24- hour notice prior to canceling my appointment. If a make-up session is scheduled within the same week, this fee will not apply.
- I understand that a "consult fee" of $20 per 15 min will apply if my child's therapist is asked to participate in a phone call or conference for more than 20 minutes.
Initials*
ATTENDANCE
- I understand that TLC has an attendance policy of 75%, meaning my child will be present for at least 3/4 sessions or attend virtually whenever unable to come to the clinic to maintain this attendance rate.
- If my child's attendance falls below 75%, my child may be placed on hold and contacted when we have cancellations only.
- I understand that if I miss 2 consecutive appointments without notice that my child will automatically be removed from the therapy schedule.
- I understand that TLC requires a current annual doctor's referral and initial hearing screening for speech services to take place.
Initials*
INSURANCE
- I understand that TLC is only in network with BCBS, United Healthcare, and Aetna private insurance plans. TLC is in network with the following BCBS plans: HMO Louisiana HMO/POS, OGB MagLocal Plus - PrefCare, OGB MagOpenAccess - PrefCare, OGB Pelican HRA/HSA PrefCare, OGB Preferred Care, Preferred Care PPO. TLC is OUT OF NETWORK with the following plans: Medicaid, Abbeville General, Blue Connect HMO/POS, Community Blue HMO/POS, OchPlus, OGB MagLocal – BlueConn, OGB MagLocal BR - CommBlue, Precision Blue HMO/POS, Signature Blue HMO/POS, TQHN
- By initialing below, I understand that if I do not have one of the plans listed above, my child will be charged private rates for services as follows: (evaluation $250-$400, 60 min session $125, 45 min session $100, 30 min session $68).
- I understand that I am responsible for knowing my co-payment amount and deductible amount and if my plan is "in network". I understand that if insurance information is not available or you do not have insurance, PAYMENT IS DUE IN FULL (see above prices) unless other arrangements have been approved by the administration.
- As a courtesy to our clients, we will verify and file your insurance; however, THIS IS NOT A GUARANTEE OF COVERAGE OR PAYMENT. We strongly suggest that you read your policy manual as it pertains to therapy coverage. Many insurance companies have stipulations, such as usually & customary fees (UCR), limited therapy sessions, limited reimbursable amounts per session, deductibles, co-payments, supplies, etc. Such stipulations should be indicated in your policy manual. YOU ARE RESPONSIBLE FOR AMOUNTS NOT COVERED by your insurance.
Initials*
PAYMENT FOR SERVICES
- I understand that "Fusion" will email me an invoice as frequently as insurance claims are approved and that TLC has no control over the approval period. Services can be paid electronically via the invoice emailed to you. Due to our HIPAA compliant platform, the invoice is only available for 7 days.
- I understand that my child’s weekly appointment time will not be guaranteed if payments are not received for services within 7 days of the date of invoice. This applies to children seen at the clinic and at school.
- I understand that Therapeutic Learning Center has the right to discharge my child if payment for service is not received within the month of services provided. Payment for services is expected following each session or at the time of service.
- I understand that if payments are received past 30 days from the date of invoice, a $10 late fee will apply. If payments are received 45 days or more from the date of service, a $20 fee will apply. Any balance 60 days or more will be turned over to an OUTSIDE COLLECTIONS SERVICE.
- If collections services or an attorney is employed to collect payments due, I will also be responsible for interest and expenses, including but not limited to costs and attorney's fees.
Initials*
OUT OF OFFICE FEES
- I understand that I will be charged a $20 out of office fee if my child is seen OUTSIDE OF THE THERAPY CLINIC SUCH AS A SCHOOL OR DAYCARE.
- I understand that it is my responsibility to notify my child’s therapist or the front office if my child is not at school or daycare for the day the therapist is scheduled to see my child.
- A no-show fee of $50 will be charged if your child is not at school or daycare and the therapist was not notified.
- I understand that I will provide the office with a credit card to keep on file for payment when my child is seen outside of the therapy clinic such as school or daycare.
Initials*
I have read and agree to follow Therapeutic Learning Center, LLC attendance and payment policies.*
Signature*

Clear
Date*

MonthDayYear
Date
Divorced/Separated Parents and Custodial Arrangements
Therapeutic Learning Center, LLC does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on your former spouse or the child’s other parent. We will be happy to provide receipts for paid medical bills for you as requested.

FINANCIAL AGREEMENT AND GUARANTEE: I accept full and complete financial responsibility for all medical and/or therapeutic services rendered to the registered patient(s) and agree to any and all insurance co-payments, deductibles, and co-insurance that may be required under the terms of my medical insurance policies, as well as pay for any medical care that is considered a “non-covered” service under the terms of my medical insurance plan.
HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care.
Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing
care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the therapist.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. Signing below indicates you understand and agree to the terms of this HIPAA policy.
Signature

Clear
Type a question
Type a question
Guarantor's name:

First NameLast Name
Child's name:

First NameLast Name
Name

First NameLast Name
Guarantor's Signature:

Clear
Type a question
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No	If yes, please explain (include dates where possible)
Tonsilitis
Tonsillectomy
Snoring
Frequent colds
Nasal congestion
Adenoidectomy
Difficulty sleeping
Breathing difficulties
Seasonal allergies
Chronic ear infections
Hearing loss
Ear (PE) tubes
Vision problems
Wears glasses
Head injuries
Genetic disorder

	Yes	No	If yes, please explain
Thumb/finger sucking
Difficulty nursing
Difficulty bottle feeding
Tongue thrust
Drooling
Picky eater
Sensitive gag reflex
Pacifier use
Reflux/colic
Messy eater
Food texture sensitivity
Tongue or lip tie
Weight issues
Choking/coughing while eating

	Hours per day (Weekday)	Hours per day (Weekend)
Watches TV
Plays with adults
Plays with other children
Plays independently

	Yes	No	Family member(s):	If yes, please explain
Speech/Language Difficulties
Learning Disabilities (ex: dyslexia)
Hearing Impairment/Deafness

	Yes	No	If yes, please explain.
Usually active/fidgety
Easily overwhelmed
Low muscle tone
Overly sensitive to sound
Clumsy
Overly sensitive to touch

Speech Client Intake Form

Birth History

Medical History

Feeding History

Social History

Developmental History

Educational/Academic History

Speech & Language Development

Guarantor Information

Insurance Information

Speech Referral and Hearing Screening

Consent

Permission Slip, Indemnification, Medical Agreement, and Grant of Rights

Payment and Attendance Policies

Divorced/Separated Parents and Custodial Arrangements

	Now	Past	Never
Eye Gaze
Facial Expression
Vocalizations
Gestures
Sign Language
Spoken Words (single words)
Spoken Words (phrases or sentences)
Physical touch (push, pull, etc.)
Low-tech AAC (e.g., picture board)
Speech Generating Device

	Yes	No	If no, please explain.
Follow simple directions?
Follow complex or multi-step directions?
Ask questions?
Understand what you are saying?
Identify objects and actions easily?
Respond correctly to yes/no questions?
Is your child's speech easily understood by most people?