• Pediatric Therapy Intake Forms

    Thank you so much for selecting Communication Cottage Therapy, LLC as your provider. We have a few important documents to complete prior to initiating services that we would appreciate your help completing. Please carefully review these documents. If you have any questions you can always email: kristin@communicationcottagetherapy.com for clarification. Thank you kindly
  • Consent for Services Form:

  • If you do not wish to receive services please initial in the box below. If you do not consent for services please initial below and we will no longer continue to pursue the on-boarding of this patient unless we are contacted again at a later date with a change of decision.

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  • HIPAA POLICY NOTICE OF PRIVACY PRACTICES

  • This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.


    The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.

    This Act gives you, the patient, significant new rights to understand and control of how your health information is used. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. HIPAA provides penalties for covered entities that misuse personal health information.
    As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

    Treatment means providing, coordinating, or managing health care and related services, by one or more health care providers. An example of this would include a physical examination.

    Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

    Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

    We may create and distribute de-identified health information by removing all references to individually identifiable information.

    We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

    The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure to family members, other relative, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.


    The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

    The right to inspect and copy your protected health information. The right to amend your protected health information.

    The right to obtain a paper copy of this notice from us upon request.

    This notice is effective as of June 1, 2020 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised notice of Privacy Practices from this office.

    You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaints with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

    Please contact the following for more information:
    The U.S. Department of Health & Human Services
    Office of Civil Rights
    200 Independence Avenue, S.W.
    Washington, D.C. 20201
    (202) 619-0257
    Toll Free: 1-877-696-6775

  • Acknowledgement of HIPAA Privacy Notice:

    This can be found on the previous page
  • Communication Cottage Therapy, LLC is required by law to keep your health
    information and records safe.


    This information may include:
    ● Notes from your doctor, teacher or other healthcare provider
    ● Medical history
    ● Evaluation results
    ● Treatment notes
    ● Plans of Care
    ● Insurance information


    We are required by law to give you a copy of our privacy notice.

    This notice tells you how your health information may be used and shared.

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  • Acknowledgement & Assumption of Risk

  • I understand that I am being asked to carefully read each of the provisions in this form.

    I acknowledge and agree to have receive therapy services from Communication Cottage Therapy, LLC and/or an employee or independent contractor employed by Communication Cottage Therapy, LLC.

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  • Authorization to Exchange Information

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  • I hereby grant Communication Cottage Therapy, LLC, permission to communicate with the following person(s) agencies regarding my child's care/services.

    Please fill in the individual's names requested to allow for us to be able to share evaluations/re-evaluations, care plans, session updates/notes, resources, medical history (etc) for the specific purpose of coordinating care, continuity of services and updating on therapy progress.

  • Child's Doctor
    Payer/Insurance Information (list all)
    Other Doctors
    Early Interventionist/Service Coordinator
    Daycare
    School
    Other Pertinent Individuals Involved in the child's care:

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  • Precautionary Coronavirus/Illness Release Form

  • Due to the 2019-2022 Outbreak of COVID 19, we are taking extra precautions with the intake of each client, health history review, and sanitizing and disinfecting practices.

    Please review the following information and sign below to acknowledge this policy and
    the hold harmless/release of liability of Communication Cottage Therapy LLC.


    Symptoms of COVID 19 Include:
    ☐Fever
    ☐Fatigue
    ☐Dry Cough
    ☐Difficulty Breathing


    I agree to the Following:
    ☐ I understand the above symptoms and affirm that I as well as household members
    and coworkers do not currently have nor have experienced any of the symptoms listed above within the last 14 days.


    ☐ I affirm that I as well as household members and co-workers have not been diagnosed with COVID 19 within the last 30 days


    ☐ I affirm that I as well as all household members have not traveled outside of the
    country or to any city outside of our own that has been considered a hot spot for COVID in the last 30 days.


    ☐ I understand that this business, Communication Cottage Therapy, LLC cannot be held liable for any exposure to the virtus or any other contagion caused by misinformation on this form or the health history provided by each patient.


    By signing below, I agree to each above statement and release Communication Cottage Therapy, LLC from any and all liability for the unintentional exposure or harm due to COVID 19 or other illnesses.


    Your therapist and all employees of this facility agree that they abide by these same
    standards and affirm the same. We also affirm that we are using universal precautions and have expanded our sanitisation to more thoroughly fight the spread of COVID 19 and other communicable conditions.

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  • Cancellation/Attendance Policy

  • Attendance and participation in therapy along with complete compliance with any associated home programs, are essential for therapeutic success.


    While Communication Cottage Therapy, LLC understands that illnesses and emergencies occur, we respectfully request that you avoid frequent cancellations or “no shows”.

    Please adhere to our following policy regarding providing Communication Cottage Therapy with advance notification for any cancellations resulting from a conflicting appointment, vacation, obligations for work or family, or any other event.


    All cancellations must be submitted (call/text - do not cancel by email) 24 hours or earlier prior to your scheduled appointment.

    Please work with your treating therapist to schedule a makeup session if possible for cancelled sessions to allow for continuity of care for the client.


    A fee of $100 (session rate) may be assessed if the following occurs:
    ● If cancellations are made less than the required 24 hours (late cancellation).
    ● If the client fails to show up for a scheduled appointment.


    The $100 fee will be billed directly to the client and not the health insurance company, as medical insurance does not provide coverage for missed sessions.


    If you cancel late (less than 24hrs) or arrive 15 minutes + late to a scheduled appointment on 3 occasions within the care plan cycle (12 weeks), Communication Cottage Therapy LLC will reserve the right to discharge the client.


    If you arrive late for a scheduled appointment, the session will still end at the scheduled time or may be cancelled.


    If you fail to appear for an appointment (no show) without providing the appropriate advance notification for 2 appointments within the care plan cycle (12 weeks), Communication Cottage Therapy LLC will reserve the right to cancel all pending appointments and to no longer offer services to you as a client.

  • I understand late cancellation and “no show” charges must be paid before any further appointments will be scheduled.

    I understand the attendance/cancellation policy and the risks of not adhering to it.

    I understand that if I do not participate in the home education plan that Communication Cottage Therapy, LLC reserves the right to discharge the client.

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  • Consent for Release of Photos/Videos

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  • Communication Preference Form

  • In an effort to ensure your privacy, it is important for us to understand your preferred method of receiving and communicating medical and administrative information pertaining to your therapy. As such, please indicate your communication preferences below.

    For medical and administrative information pertaining to me such as clinical documentation, appointment reminders, therapy updates etc. I hereby grant permission to Communication Cottage Therapy to do the following:


    Written Documentation and Verbal Information

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  • General Acknowledgement of Forms

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  • Should be Empty: