The Speech Lady Client Intake Form Logo
  • 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. 

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  • 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.

  • 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.

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  • 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. 

  • 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.

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  • 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. 

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  • Consent to Release Information

  • 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.

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  • Insurance Information

  • Demographic Information

  • Note: We use Clinic Source for all client charts which is HIPAA-Compliant and provides industry-leading data system security. 

  • Parent / Guardian 1

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  • Parent / Guardian 2

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  • Developmental and Health History

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  • Prenatal Health

  • Birth History

  • Health/Nutrition

  • Health/Development

  • At what age did your child first:

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