Therapy OPS Tongue Thrust Intake Form

Tongue Thrust Intake Form
Please Note: Every question included in this intake is used to adequately prepare for your or your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's First and Last Name:
Patient's age:
Patient's Birth Date:

MonthDayYear
Is the patient a minor (under 18)?
My child is:
Age of placement:
"Other" explanation
Sex
Parent/Guardian 1 Name:
Relationship to child
Parent/Guardian 1 Cell Phone Number

Area CodePhone Number
Please send me text reminders:
I would like my reminder:
Parent/Guardian 1 Email address:
Parent/Guardian 1 Date of Birth:
Parent/Guardian 2 Name:
Relationship to Child
Parent/Guardian 2 Cell Phone Number

Area CodePhone Number
Parent/Guardian 2 Email Address:
Parent/Guardian 2 Date of Birth:
Who has legal custody of the child?

Other
Who is legally authorized to make health care/therapy decisions for the child?

Other
Is there a court order, custody agreement, guardianship document, Delegation of Parental Authority (DOPA), or other legal document that affects who may make health care decisions or receive information about this child?
Please upload any applicable documents:

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Is anyone other than a parent or legal guardian authorized to make health care/therapy decisions for this child?
If yes, please provide their name
Relationship to the child
Type of Legal Authority (please provide a copy of the current documentation via email or fax)

Other
Are there any restrictions on contacting or providing information to any parent, guardian, or other individual associated with this child?
Please explain
Please provide documentation (if different from above upload)

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If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Please send me text reminders:
I would like my reminder:
Email address for documents:
Who currently lives with the patient?
How long have you lived here (St. Paul, south Metro, MN)?
Physician/Primary Care Provider (required to obtain a doctors order in order to bill insurance):
Primary Care Provider Clinic Name (required to obtain a doctors order in order to bill insurance):
Primary language spoken in the home:
How did you hear about us:
Medical Diagnosis:
Allergies (including nasal congestion):
Current Medications:
School/Program of attendance:
Grade:
Does the patient receive Special Education Services?
If, yes, what?
Describe your current concerns as it relates to tongue thrust:
e.g., open bite, teeth have shifted, cannot get braces until fixed, etc
List past evaluations and therapy:
Is the patient currently receiving therapy at this time?
If yes, what type of therapy and where?
List past and current orthodontic work:
Has there been any reversals in orthodontic work?
Has anyone in your immediate family been diagnosed with tongue thrust?
Prenatal/Birth History

Additional details for prenatal/birth history (weeks premature, concerns, etc):
Medical History
History of:
Explanation of medical history items:
Are immunizations current
Has the patient ever had
Description of above concerns:
Tongue Thrust History

The following questions help us determine if there is a possible cause for the tongue thrust. Please answer all completely

Did the patient have difficulty

Rows	Yes	No	Unknown
Sucking
Swallowing
Chewing
Changing to solids

Age transitioned from bottles to cup
Age transitioned from sippy cup to open cup
When did pacifier use stop and how often was it used?
History of thumb or finger sucking?
If yes, when did the sucking stop?
Speech/Language Skills
Which sounds, if any, are incorrect?
Do these sounds impact intelligibility?
Does the patient have difficulty following directions
Social Development

Would you describe the patient as having:

Rows	Yes	No	N/A
Impulsive
Nervous tics/behaviors
Difficulty learning new things
Aggressive behavior

Current Status

The following questions help us plan therapy activities and foods/drinks with which to practice swallowing. Please complete each question.
Favorite foods:
Adverse foods (if any):
List any dietary restrictions:
Insurance Information and Signatures
Insurance Carrier:
Policy Holder:
Employer:
Group Number:
Policy Number:
Does the patient have secondary insurance?
Secondary Insurance Policy Number:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Therapy OPS. I understand that I am financially responsible for any balance. I authorize Therapy OPS or my insurance company to release any information required to process my claims.

I have custody for the above minor and have been granted the right to legally make all health/therapy decisions regarding him/her. Please list others that share custody and are priveledged to health information:
Others than yourself who have custody of the above named minor:
Signature of parent/guardian/self
Should be Empty:

Rows	Yes	No	Unknown
Full term
Feeding difficulties

Tongue Thrust Intake Form

Prenatal/Birth History

Medical History

Tongue Thrust History

Speech/Language Skills

Social Development

Current Status

Insurance Information and Signatures