Pediatric Therapy Intake Forms

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:
I CONSENT: *
Please initial to confirm consent for services *
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.
Should You NOT wish to receive services please initial below.
Child's Name*

First Name Last Name
Child's Date of Birth:*
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
Signature of Legal Guardian: *

Clear

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.
I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.*
I acknowledge that I have received a copy of Communication Cottage Therapy LLC’s HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.*
I understand Communication Cottage Therapy LLC cannot disclose my health information other than as specified in the notice.*
I understand that Communication Cottage Therapy LLC reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.*
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
By Signing this form I agree to and acknowledge the way that health information may be shared as outlined above. Signature of Legal Guardian: *

Clear

Acknowledgement & Assumption of Risk
I parent/guardian's name 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.
I acknowledge that there is some inherent risks associated with the use of therapy equipment that cannot be eliminated regardless of the care taken to avoid injuries. *
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
Signature of Legal Guardian: *

Clear

Authorization to Exchange Information
Client/Child's Name:*

First Name Last Name
Child's Date of Birth*

MonthDay Year
Date
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
I blanks 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 blanks
Payer/Insurance Information (list all)type here
Other Doctorstype here
Early Interventionist/Service Coordinatortype here
Daycaretype here
Schooltype here
Other Pertinent Individuals Involved in the child's care:type here
I grant permission to exchange information via written and mailed report, phone call, meeting, email, or fax*
I understand that unless revoked, this authorization will remain valid until a written revocation of this authorization is presented*
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
Signature of Legal Guardian: *

Clear

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.
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
Signature of Legal Guardian: *

Clear

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

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

Iblanks understand that if I do not participate in the home education plan that Communication Cottage Therapy, LLC reserves the right to discharge the client.
Child/Client's Full Name

First Name Last Name
Child/Client Date of Birth

MonthDay Year
Date
Signature of Legal Guardian

Clear
Name of Legal Guardian

First Name Last Name
Date of Completion

MonthDay Year
Date

Consent for Release of Photos/Videos
Child/Client's Full Name

First Name Last Name
Child/Client's Date of Birth

MonthDay Year
Date
I give consent to Communication Cottage Therapy, LLC or any party authorized by Communication Cottage Therapy, LLC to photograph and/or video record the client indicated above in connection with their therapy sessions, for any purpose subject to the therapist’s discretion including but not limited to educational publication, for teaching purposes, and demonstration of progression of their skills.
I authorize Communication Cottage Therapy, LLC to use pictures of the child listed above for promotional purposes (ex. social media,website)
I acknowledge that I will receive no financial compensation for providing consent since my participation with Communication Cottage Therapy, LLC in providing my consent and release is voluntary.
I hereby release Communication Cottage Therapy, LLC, their contractors, their employees and/or any third parties involved in the creation or publication of Communication Cottage Therapy, LLC. Publication from any and all liability that may arise in connection with the expressed and implied use of all photographs and videos outlined in this form.
I reserve the right to revoke this agreement at any time. If I would like to revoke this I will submit my intent to revoke this agreement in writing via email so that Communication Cottage Therapy, LLC can amend this agreement and update records.
I am the client, parent or legal guardian of the person named below and have the legal authority to execute this consent and release
Legal Guardian/Parent's Name:

First Name Last Name
Legal Guardian/Parent's Signature:

Clear
Date of Form Completion

MonthDay Year
Date

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
I grant permission to provide me with written communication via HIPAA compliant encrypted email service via my email provided.*
I grant permission to provide me with written communication via unencrypted email service. Iunderstand that with this option, written communication may be viewed by an unintended third partyand I fully accept this risk.*
I grant permission to provide me with written communication via USPS in an unmarked envelope.*
I elect to receive clinical information in person or via telephone through the number provided.*
I grant permission to leave relevant medical information on my answering machine or voicemail. Information about permission to release medical information to other members can be found in the Authorization to Exchange, Obtain and Release Information Form.*
I understand that it is my responsibility to inform the practice of changes to my preferred contact information or my communication preferences, as well as, to revoke this authorization at any time.*
Name of Child/Client

First Name Last Name
Date of Birth

MonthDay Year
Date
Signature of Parent/Legal Guardian

Clear
Relationship to Client
Date of Form Completion

MonthDay Year
Date

General Acknowledgement of Forms
I hereby acknowledge and agree that I had read all of the forms and documents provided to me in connection with evaluation and treatment provided by Communication Cottage Therapy, LLC and/or their employees*
I understand the meaning and intent of the provided forms and agree to all content included*
I have been given an opportunity to ask questions about the provided forms and all questions I’ve asked have been answered to my satisfaction by my provider with Communication Cottage Therapy, LLC*
I understand that I can reach out to kristin@communicationcottagetherapy.com or my specific provider with any questions or concerns as well as positive/negative feedback at any time in the on-boarding and treatment process.*
Date of Form Completion: *
Legal Guardian's Name*

First Name Last Name
Relationship to Client:*
Signature of Legal Guardian: *

Clear
Should be Empty:

Pediatric Therapy Intake Forms

Consent for Services Form:

HIPAA POLICY NOTICE OF PRIVACY PRACTICES

Acknowledgement of HIPAA Privacy Notice:

Acknowledgement & Assumption of Risk

Authorization to Exchange Information

Precautionary Coronavirus/Illness Release Form

Cancellation/Attendance Policy

Consent for Release of Photos/Videos

Communication Preference Form

General Acknowledgement of Forms