The Speech Lady Client Intake Form

Type a question
The Speech Lady Client Intake Form
Please Note:

This form will take approximately 10-15 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature and serve as in initial notice of our clinics policies and procedures.

Please do not print these forms. Please fill them out online at least 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential.
Page 1 of 13

Patient Consent Form for Collection, Use, and Disclosure of Personal Information
Privacy of your personal information is an important part of The Speech Lady's practice while we are serving your family. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

At The Speech Lady, we can assure you that:
- Only necessary information is collected about you;
- We only share your information with your consent
The Speech Lady will collect, use and disclose information about you for the following purposes:
- To assess your child's health, speech/language concerns
- To provide speech language therapy/ treatment
- To advise you of treatment options
- To establish and maintain contact with you
- To send you newsletters and other information mailings
- To remind you of upcoming appointments
- To communicate with other treating health-care providers
- To allow us to efficiently follow-up for treatment, care and billing
- To complete claims for insurance purposes
- To invoice for services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.
I have reviewed the above information that explains how The Speech Lady PLLC will use my personal information and the steps that the clinic is taking to protect my information.

I agree that The Speech Lady, PLLC can collect, use and disclose personal information as set out above in the information about the clinic's privacy policies.
Full Name*

First NameLast Name
Date

MonthDayYear
I have reviewed the above information that explains how The Speech Lady, PLLC will use my personal information and the steps that the clinic is taking to protect my information. I agree that The Speech Lady, PLLC can collect, use and disclose personal information about (the signed) as set out above in the information about the clinic's privacy policies. Signature*

Clear
Page 3 of 13

Financial Agreement/ Attendance Policies

Policies and Financial Agreement/Disclosures

Polices/Procedures Regarding Course of Treatment

Information and expectations regarding therapeutic timelines and communications

Informed Consent
Please note that this form must be signed prior to your first appointment.
Our goal is to make progress with your child's speech and/or language. Our priority is to serve your family, taking all factors into consideration. A good prognosis is not only dependent on our practice using evidence-based techniques and methods, but also depends on attendance, tolerance/appropriateness for therapy, client compliance, client motivation, other medical diagnosis, health issues and support from family and caregivers. We cannot guarantee specific outcomes, however, we will always be professional, compassionate, and conduct ourselves with integrity, and treat you and your family with the respect you deserve.

I understand:

1) Therapy may be provided by a student clinician, intern, or speech pathologist assistant or speech language pathologist (SLP) to meet theraputic goals. Sessions conducted by student clinicians, interns or speech language pathologist assistants will be conducted in collaboration with a licensed SLP at The Speech Lady. Additionally, the supervising SLP will be responsible for providing interpretation of evaluations and reporting progress towards care plans.

2) The clinic does not guarantee treatment results.

3) That The Speech Lady will explain to me the exact nature of any treatment provided for my child and will answer any questions I may have.

4) I am free to withdraw my consent and to discontinue treatment at any time.
Full Name (child)*

First NameLast Name
Full Name (of Guardian)*

First NameLast Name
Date

MonthDayYear
Signature of Patient or Guardian Indicating that they have read and agree to Informed Consent*

Clear
Page 4 of 13

Email Consent
In order to contact patients about clinic changes, promotions, products, events, newsletters, workshops and programs, we request your consent below. You may choose to withdraw consent at any time and you will no longer receive emails from The Speech Lady, PLLC.
I consent to being emailed by The Speech Lady, PLLC for purposes of communication, and learning of changes in the clinic.*

Clear
Page 5 of 13

Consent to Release Information
I authorize the release and exchange of protected health information between The Speech Lady, PLLC the following individuals:
If your child is in daycare, preschool or school aged, please list the name of the school and their contact number: *
If not in school please type N/A.
Do you give consent for your therapist to contact the school to coordinate care as needed to facilitate therapy: *

Financial Responsibility - Insurance Notice
Thank you for choosing The Speech Lady for your child’s speech and language therapy needs.

Your child has been registered with our practice as a Medicaid or Medicaid Managed Care recipient (HealthyBlue of NC, UnitedHealthcare Community Plan of NC, or WellCare of NC) ONLY, as we do not accept, nor are we in network with, any commercial insurance carriers.

If it is determined that your child has multiple insurance coverages after services are rendered, you will be held responsible for 100% of charges for all services rendered.

If there is an error on your child’s Medicaid file showing that there are multiple coverages, you can place services on hold for a maximum of two weeks while you work with your DSS caseworker and the Medicaid/Managed Care plan to have your other insurance information updated appropriately. However, you may opt to pay at the time of service for your child’s therapy session to
hold their place on the schedule.

If your child is eligible for multiple insurance coverages, you may opt to be registered with our practice as a private pay patient. Our practice will email you a monthly statement, listing the services rendered, that you can file with your commercial insurance for potential reimbursement. You cannot file any
remaining balance to Medicaid or a Medicaid Managed Care Plan.

I acknowledge that my child is only covered by NC Medicaid, HealthyBlue of NC, UnitedHealthcare Community Plan of NC, or Wellcare of NC and if it is determined by the previously mentioned insurers that my child has other insurance, I acknowledge that I am responsible for 100% of charges for all
services rendered.

AND/OR

I acknowledge that I am waiving my right to file claims for the benefits administered by NC Medicaid, HealthyBlue of NC, UnitedHealthcare Community Plan of NC, and WellCare of NC if my child is eligible for a primary commercial insurance plan. I accept that I am personally responsible for the payment of
services rendered by The Speech Lady at the time services are rendered.

This document will be effective for the entirety of your child’s treatment with The Speech Lady.
Signature*

Clear

Insurance Information
Primary Insurance Provider *
N/a if not applicable
Primary Subscriber ID # and Group #*
N/a if not applicable
Do you have any other insurance coverage?*
Additional Insurance Provider*
N/a if does not apply
Subscriber # and Group #*
N/a if does not apply

Demographic Information
Note: We use Clinic Source for all client charts which is HIPAA-Compliant and provides industry-leading data system security.
Your child's name:*

First NameLast Name
Birth Date*

MonthDayYear
Sex / Gender:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent / Guardian 1
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Parent / Guardian 2
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Preferred Contact? (This is how your therapist will contact you):*

CellHomeEmail
May We Leave Messages Pertaining to Your Child's Visits?*

YesNo
Emergency Contact Name:*

First NameLast Name
Emergency Contact Number:*

Area CodePhone Number
Relation to the Patient:
Pediatrician's Practice, Physician Name and Phone Number*
Referred by, if different than from pediatrician:
How did you hear about The Speech Lady? *

Developmental and Health History
What are your specific concerns regarding your child's speech/language skills? Check all that apply*
Has your child had a speech language evaluation in the last 6 months? If so, when and where?*
If your child has had a recent evaluation, please upload it here:

Browse Files

Cancelof
Does your child receive or have a history of other developmental therapies: *
(I.e., ABA, OT, PT, Play, Feeding, etc.)
Type of therapies
Please provide the name of the provider, frequency of visits, and how long your child has been participating: *
Does your child have an IEP or 504? *
How would describe your child's general state of health? *
Any Family History of speech or language delays? If so, what relation to the child? *
Please list any current medical diagnosis: *
Past Diagnoses and Past Medical History:
Please indicate any serious conditions, illnesses, or injuries and any hospitalizations, along with approximate dates:*
Food Allergies, Sensitivities and Intolerances
Environmental Allergies (latex, dust mites, animal dander / fur, hayfever etc)
Prescribed or Over-the-Counter Medications
Did your child pass their newborn hearing screening? *
Do you have any concerns with your child's hearing? *
Number of ear infections: *
What medical intervention required to treat ear infections? *
Does your child get regular developmental screening tests done by their pediatrician (hearing, vision, etc.)*

YesNoUnknown
Which Screening Tests has your child had? (Hearing, Vision, etc.)
Prenatal Health
Did the Mother receive prenatal care? *
Did the mother experience any of the following during pregnancy? *
Did the mother use any of the following during pregnancy? *
Describe
Birth History
Pregnancy Term Length*
How many weeks premature / late
N/a if does not apply
Length of Labor
Birth Weight*
Birth Length
Type of Birth*
Relevant birth interventions:*
Did you experience any of the following after birth complications:*
Please explain any other complications or note-worthy experiences during birth: *

Was your child Breastfed? *
Any early feeding difficulties? *
i.e., difficulty nursing/latching, reflux, poor appetite, failure to thrive, etc.
If yes, explain:
Health/Nutrition
Does your child eat a regular diet? Is he/she a picky eater? Please explain.*
Did your child ever experience colic?*
How severe?*
Does your child have any dietary restrictions? (Religious, vegetarian / vegan, etc)?*
Typical Diet (breakfast, lunch, dinner; snacks) *
Does your child have a history of extended pacifier or thumb sucking? If so, until what age? *
What kind of cup does your child consume beverages?*
Any history of snoring, sleep apnea, frequent sleep disturbances?

Health/Development
How was your child's health in the first year? *
At what age did your child first:
Sit Up?*
Crawl?*
Walk?*
First Words?*
Combined Words?*
Do you have any concerns about your child's social/ emotional/ behavioral development? *
if so, please explain:
How would you describe your child's temperament? *
What are your child's favorite activities?*
How would you describe your child's behaviour and performance at school?*
Is there anything that you feel is important that has not been covered?

AUTHORIZATION: I certify that this information is true and correct to the best of my knowledge. I am the legal guardian of this minor, and I give The Speech Lady, PLLC permission to evaluate and treat my child as needed.

Clear
Should be Empty:

The Speech Lady Client Intake Form

Patient Consent Form for Collection, Use, and Disclosure of Personal Information

Financial Agreement/ Attendance Policies

Polices/Procedures Regarding Course of Treatment

Informed Consent

Email Consent

Consent to Release Information

Financial Responsibility - Insurance Notice

Insurance Information

Demographic Information

Developmental and Health History

Prenatal Health

Birth History

Health/Nutrition

Health/Development