2022 New Patient Intake Form

Patient Information
Patient Name*

First Name Last Name
Preferred Name
Date of Birth*

MonthDay Year
Date
Primary Language
Other languages spoken in the home
Address*

Street Address

Street Address Line 2

City State

Zip Code
Gender*

MaleFemale
Referring Physician*
Phone Number

Area Code Phone Number
Pediatrician (if different)
Phone Number

Area Code Phone Number
How did you hear about us?*

Parent/Guardian Information
Parent Guardian 1*

First Name Last Name
Relationship to Child*
Email Address*
Phone Number*

Area Code Phone Number
Address Same as Patient?*

YesNo
Address

Street Address

Street Address Line 2

City State

Zip Code
Parent Guardian 2*

First Name Last Name
Relationship to Child*
Phone Number*

Area Code Phone Number
Address Same as Patient?

YesNo
Address

Street Address

Street Address Line 2

City State

Zip Code

Emergency Contact
Contact Name*

First Name Last Name
Relationship to Child*
Phone Number*

Area Code Phone Number

Insurance Information
Will you be filing with your medical insurance provider?*

YesNo
Primary Insured Name*

First Name Last Name
Relationship to Patient*
Date of Birth*

MonthDay Year
Date
Insurance Company*
Provider Phone Number
Policy Number / Subscriber ID*
Group Number*
Does the patient have secondary insurance coverage?

YesNo
Insured Name*

First Name Last Name
Relationship to Patient*
Social Security Number
Insurance Company*
Provider Phone Number
Policy Number / Subscriber ID*
Group Number*

	Age
Rolling
Sitting unsupported
Crawling
Walking
Running
Jumping
Babbling
Said first word
Put two words together

Consent to Treat
Insurance Coverage

Copays, deductibles, and coinsurance are due at the time of service. Unless a written payment plan is in place, all outstanding balances are due prior to the next therapy appointment. Mighty Kids Therapy will verify benefits upon initial appointment. Verification of benefits is not a guarantee of coverage or payment, and all insurance payments are subject medical necessity and eligibility at the time services are rendered. Knowledge of maximum number of visits, deductible amounts, and out-of-pocket maximums are your responsibility. It is your responsibility to update Mighty Kids Therapy regarding loss of coverage or any changes to your insurance. If you are unable to provide Mighty Kids Therapy with your current insurance information prior to your child’s initial appointment, payment will be due in full when your child arrives for the appointment.

Developmental Delay Coverage

Many Insurance plans DO NOT have developmental delay coverage. Even though a pediatrician recommends services, many pediatric therapy diagnoses are considered developmental delays and are excluded from therapy coverage. Please be sure to verify your benefits with your insurance carrier and/or employer to determine whether there is coverage for developmental delay. It is your responsibility to know your insurance policy coverage and limitations, including any exclusions. Mighty Kids Therapy will gladly provide you with any information that is required to verify benefits with your insurance carrier. If it is determined that there is no coverage, you can choose to discontinue therapy services or continue with therapy service at the self-pay rate.

Divorce Decree

Mighty Kids Therapy is not party to your divorce decree and is not authorized to enforce compliance. Payment is due at the time of service by the accompanying parent.

Authorization and Consent for Treatment

Mighty Kids Therapy will render routine clinical care including evaluations, educational services, and therapy activities/procedures during receipt of service, and carry out orders of the child’s physician, including consultants, associates, and assistants. Mighty Kids Therapy has not made any guarantee or warranty as to the results of any services or treatments given.

Authorization for Release of Information

Mighty Kids Therapy will furnish and release medical information to your private insurance carrier, or other third-party payer, as may be required for determination of benefits payable. Respecting privacy and anonymity, your child’s records may be reviewed for statistical purposes. Mighty Kids Therapy may communicate all aspects of your child’s care to the referring physician, primary care physician, and any other physician requested by parents/guardians.
I certify that any and all information given by me to Mighty Kids Therapy is correct, to the best of my knowledge. I agree that a copy of this form shall be valid as the original and will not expire. I have read this form (or it has been read to me) and I certify and understand and agree to all of its conditions.*

Clear
Date*

MonthDay Year
Date

Photo Release Form
During your child’s therapy, Mighty Kids Therapy may photograph and/or videotape your child for the purpose of treatment and education. These photos or videos will not be released to the public.

Mighty Kids Therapy may request to photograph your child for the purpose of professional marketing. In this case, your child’s image may be included on materials such as flyers, brochures, Mighty Kids Therapy website, and/or Mighty Kids Therapy social media platforms (Facebook, Instagram, etc).
Please select one of the following:*

I DO consent to my child being photographed and/or videotaped for the reasons selected below (please answer the next question)I DO NOT consent to my child being photographed and/or videotaped for any purpose.
I hereby authorize Mighty Kids Therapy to photograph and/or videotape my child for the following purpose(s):*

Treatment and education (internal use only)Digital and print marketing materialsSocial mediaDisplay in the clinic

Attendance Policies
At Mighty Kids Therapy, we are committed to providing the highest quality of care for your child. This is best accomplished by consistent attendance and on-time arrival to all scheduled appointments. Missed appointments and late arrivals can inhibit your child’s progress. Please respect our dedication to your child by committing to scheduled therapy appointments according to the prescribed treatment plan.
Please carefully review and acknowledge the following policies:*

75% attendance is required for all recurring appointments. Patients who fail to maintain this will forfeit their recurring appointment.Patients who arrive more than 10 minutes late to the scheduled appointment cannot be seen for therapy. The appointment will need to be rescheduled and a $30 Missed Appointment fee will apply.24-hour cancellation notice is required for all cancellations. Patients who do not provide 24-hour notice will be charged a $30 Missed Appointment fee.Patients who fail to show up for their scheduled appointment and do not provide notice will incur a $30 Missed Appointment fee. After 2 occurrences, patients will forfeit their recurring appointment.Caregivers who do not attend therapy session are required to return to the office 10 minutes prior to the session ending. Caregivers who do not return on time will be asked to remain on the premises for future sessions.Caregivers are required to stay in the clinic during all 5:00 pm sessions.
Acknowledgment

I have carefully read, understand, and agree to the attendance policy at Mighty Kids Therapy.
Signature*

Clear
Date*

MonthDay Year
Date

Should be Empty:

Patient Information

Parent/Guardian Information

Emergency Contact

Insurance Information

Medical History

Areas of Concern

Consent to Treat

Photo Release Form

Attendance Policies