FFTC Full Intake Packet

INTAKE PACKET

Please out each section, omitting any sections that do not apply
IDENTIFYING INFORMATION

Medical History
Thank you for taking the time to fill out this form as completely and honestly as possible. Your input plays an important role in the evaluation process. All the information on this form is confidential and will not be released without your permission.
Name of Parent/Guardian completing this form
Phone Number

Area CodePhone Number
Email
example@example.com
How is the child related to you
Patient’s Name
Patient Date of Birth

MonthDayYear
Date
Age
Sex
What do you hope to gain from this evaluation?

FAMILY BACKGROUND
Mother’s Name
Mother’s Age
Mothers Occupation
Father’s Name
Father’s Age
Fathers Occupation
If not your biological child, at what age did he/she come into your home

List any family members living in the same house as child

	1	2	3	4	5
Name
Age
Relation

Does your child have a Medical Diagnosis? Please explain
When was the child diagnosed
Does anyone related to this child have speech, language, hearing, learning, mental, medical, social, behavioral, or physical development delays

YesNo
If yes, Please describe delay and how they are related to patient
Languages Spoken in Home
Are there any cultural or religious factors that may affect the child’s treatment?

Legal Intake Documents

Please complete each section
Acknowledgement of Risk
In consideration of the services of Firefly Therapy Clinic their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses (hereafter collectively referred to as “FTC”) I agree as follows: Although FTC has taken reasonable steps to provide me with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, FTC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. FTC does not want to frighten me or reduce my enthusiasm for this activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks. The hazards of walking on uneven terrain, slips and falls; slipping and falling on the rock wall, crashing on trampoline, falling from the swing, being hit by a ball or toy, falling from a chair, choking, allergic reaction; my own physical condition and the physical exertion associated with these activities. I am aware that FTC entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different from other activities and that I have responsibilities as a participant. I acknowledge that the staff of FTC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children.
I, as the legal parent or guardian of the patient herby give permission for the patient to participate in the activity and further agree, individually and on behalf of the patient to the above terms. By checking this box, I acknowledge that I have read and understand the terms of this document
Patient Name*

Attendance Policy
Appointments are scheduled into available standing appointment slots. Once you have been scheduled into an appointment time, the therapist has committed this time to you. All scheduling must go through the front office.

If you are unable to keep a scheduled appointment, you must give ample notice (within 24 hours of the appointment time

Missing or cancelling any 3 appointments out of 5 continuous appointments will result in your child being immediately removed from the schedule. More than 1 no-show may also result in your child being immediately removed from the schedule.

As in accordance with clinic policy and for the respect of patient, no children (other than those being treated by the therapist) are allowed in the gym or treatment rooms. Please keep any visiting children in the waiting area.

If the parent or guardian leaves the clinic during the patient’s session, they must return 5 minutes prior to the end of the session. Therapists and office staff cannot be held responsible for children beyond the scheduled appointment time

If your child is seen at preschool or daycare, and your child is not in attendance on the scheduled day of therapy, it is your responsibility to contact the therapist to inform them of a cancellation for that day,

Please Note: Due to limited scheduling availability, we ask that all patients attend their scheduled treatments. When an appointment is applied to our schedule, that time is reserved to meet your child’s needs. We work hard to accommodate each of our patients. Continuous neglect to follow the regulations stated in this policy could lead to termination and/or change of status to your remaining treatments and/or sessions. Thank you in advance for your understanding and cooperation in this matter.
By checking this box, I acknowledge that I have read and understand the terms of the attendance policy
Patient Name*

HIPPA Consent
I give Firefly Therapy Clinic LLC my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews. Communication may be include, but is not limited to hospital, medical service company, health care company, insurance company, workers compensation carrier, welfare departments, patients employer, previous speech clinics, school teachers/aids/administrators. I have been informed that I may review the practice/clinic's Notice of Privacy Practices for a more complete description of uses and disclosures before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice/clinic. I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

All information obtained will be kept private and used only for the planning of services or for billing for services provided

Please list the names of service providers that may be contacted by Firefly Therapy Clinic LLC
Provider Name and Provider Type (MD, Clinic, School)
By checking this box, I acknowledge that I have read and understand the terms of this HIPPA Consent form
Patient Name*

Authorization for Treatment
I consent to the treatment necessary for the below named patient, including physical therapy, occupational therapy, speech therapy, behavior analysis/therapy and/or any other related services that the provider or physician advise to be necessary.
Payment/Insurance Authorization
I authorize for all insurance/Medicaid payments to be made directly to Firefly Therapy Clinic LLC for therapy services rendered. I acknowledge that I am financially responsible for all charges not covered by this assignment. I further acknowledge that my insurance company may limit therapy benefits. I will be responsible for all charges accrued if my insurance denies service. I authorize Firefly Therapy Clinic LLC to release to the Social Security Administration, its intermediaries or carrier's information needed for the claim or any related Medicare Claim.

Private Pay rates are available for families with no insurance/inactive insurance or with insurance that does not cover services. Please see the front desk for more information. Private Pay rates are not available to families that have active insurance.
I, as the legal parent or guardian of the patient herby give permission for the patient to participate in therapy and further agree, individually and on behalf of the patient to the above terms. By checking this box, I acknowledge that I have read and understand the terms of this document
Patient Name*

Parent/ Guardian Drop off - Pick Up Policy
Firefly Therapy Clinic allows drop off and pick up of children during therapy. We require all parents, guardians and others who are dropping off, or picking up to follow these Guidelines.
- Bring the child into the waiting room and stay with them until the therapist has arrived to take them back for treatment. Please do not leave children unattended in the waiting room
- Arrive a minimum of 5 minutes prior to the end of the appointment to pick up the child
- Children will NOT be released to anyone other than the parent or guardian signing this intake packet, unless listed below
- Should you require a non listed individual to pick up your child, please contact the clinic prior to the appointment so we may update our list.
THERAPIST WILL NOT RELEASE A CHILD TO ANYONE other than the signer of this intake, without them being added to this list OR with verbal or written consent.
Please list everyone that Firefly Therapy Clinic has permission to release the child

Authorization and Consent Form
I have read and understand the intake packet and sign below as agreement to each section
- Acknowledgment of risk
- Attendence Policy
- Authorization for Treatment
- Payment/Insurance Authorization
- HIPPA Consent
- Parent/Guardian Pick Up Policy
Patient Name*
Patient DOB*

MonthDayYear
Date
Signature*

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Parent/Guardian Name*
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INTAKE PACKET

IDENTIFYING INFORMATION

FAMILY BACKGROUND

Birth History

HEALTH / MEDICAL HISTORY

COMMUNICATION DEVELOPMENT

FEEDING HISTORY

Developmental History

Academic/Therapy History

Legal Intake Documents

Acknowledgement of Risk

Attendance Policy

HIPPA Consent

Authorization for Treatment

Payment/Insurance Authorization

Parent/ Guardian Drop off - Pick Up Policy

Authorization and Consent Form