Speech Client Intake Form

Speech Client Intake Form
General Info
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):
Preferred location for services:*

Metairie Location- 3329 Metairie Rd.Elmwood Location- 524 Elmwood Park Blvd.No preference
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 BlocksnoneTalkin' Toddlers
What is their start date for the day program and how often will they be attending?
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
Referred to our clinic by?*
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 days/times are you available for an evaluation?

	Approximate age
Sat alone
Crawled
Walked
Toilet trained
Grasped crayon/pencil
Began to scribble/draw

	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.

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

Browse Files
Driver's License Cancelof
Do you have a prescription for speech therapy services (YES/NO)*
If yes, please upload a copy of the prescription for Speech Therapy services. (If no, we need this document for regular sessions. The pediatrician can write a prescription for speech services as long as the child has attended their most recent annual appointment.)

Browse Files
Prescription Cancelof
Please upload a copy of hearing evaluation within the last year.

Browse Files
Hearing Results Cancelof

Please upload a copy of your driver's license.

Browse Files
Driver's License Cancelof
Consent and Policies
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 hereby give Therapeutic Learning Center, LLC permission to evaluate and treat my child, and 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 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..*
Payment and Attendance Policy:

Please Read This Carefully

I understand that I will be charged a LATE CANCELLATION fee of $25 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 I will be charged a LATE CANCELLATION fee of $35 if I cancel within 4 hours of my appointment time.

I understand that I will be charged a NO-SHOW fee of $50 if I fail to show for my appointment.

I understand that I am responsible for knowing my co-payment amount and deductible amount.

I understand that if insurance information is not available or you do not have insurance, payment is due in full 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.

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 service. 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 timely. 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 service, 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 attorneys’ 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 school or daycare.

I understand that it is my responsibility to notify my child’s therapist if my child is not at school or daycare when the therapist is scheduled to see your child. A no-show fee 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.

Signing below indicates you understand and agree to the terms of this policy.
Signature

Clear
-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.*
- 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. *
- 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 attorneys’ 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.*
- 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%, your child may be placed on the "stand by list" contacted when we have cancellations only. - I understand that if I miss 2 consecutive appointments without notice that my child will be removed from the therapy schedule. - I understand that TLC requires a current annual doctor's referral for OT services to take place. *
Signature

Clear
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.
Child's name:

First NameLast Name
Guarantor's name:

First NameLast Name
I have read and agree to follow Therapeutic Learning Center, LLC office and payment policies.*
Guarantor's Signature:

Clear
Date*

MonthDayYear
Date
12 Week Therapy Session Duration/No-Show/Cancellation Policy

Please read this carefully.

12 Week Therapy Session Duration

We provide therapy in 12-week intervals. At the end of 12 weeks, you will meet with your therapist to discuss your child’s progress, attendance (see below for the 75% attendance requirement), and together, determine whether continued services will benefit your child.

No-Show/Cancellation

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable; however, advance notification allows us to fulfill other client’s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 30, 45 & 60-minute treatments, missed appointments are a significant inconvenience to your occupational therapist, the clinic, and other clients. For the benefit of our clients and to optimize our therapist’s time, advanced notice for cancellations is requested.

We reserve your child’s therapy appointment times on a one to one basis. As a clinic policy, we do not double-book our clients so that we may provide optimum treatment for all our clients. We require 24-hour notice for all cancellations as it allows us to place another client in your canceled appointment period to receive needed treatment. If the appointment is not canceled outside of 24-hours, your appointment will be considered a “no show” and a $50 no show fee will be reflected on your account. We require a 75% attendance rate to keep your weekly appointment time. If the appointment can be rescheduled within the week, the missed appointment will not count against your attendance rate. We will allow for one “pass/missed appt” if the appointment is not canceled outside of the 24 hours if your child is sick and missing the appointment is unavoidable.

After missing two consecutive appointments without notice or if you fail to maintain the 75% attendance rate, we reserve the right to place your child on a “stand by list” and services will be placed on hold or discharged.

Thank you for providing our office and our clients with this courtesy. Signing below indicates you understand and agree to the terms of this policy.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No	Family member(s):
Speech/Language Difficulties
Learning Disabilities (ex: dyslexia)
Hearing Impairment/Deafness

	Yes	No
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?

Speech Client Intake Form

General Info

Social History

Birth History

Medical History

Feeding/Eating History

Developmental History

Educational/Academic History

Speech & Language Development

Guarantor Information

Insurance Information

Consent and Policies