Journey Pediatric Therapy Initial Intake Form & Telehealth Form

Initial Intake Form
All information is held in strictest confidence. At no point is information disclosed or shared without the client’s written consent.
Client's Full Name*

First NameMiddle NameLast Name
Preferred Name (if Different)
Child's Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState/Territory

Postal / Zip CodeCountry
Mailing Address (if Different than Above)

Mailing Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Birth Sex*

MaleFemale
E-mail*
Primary Care Physician*
Primary Care Physician's Phone Number

Area CodePhone Number
Referring Physician/Provider
Medications
Allergies
Additional Information:
Family Information
1st Parent/Guardian *

First Name Last Name
1st Parent/Guardian Date of Birth*

MonthDayYear
Date
1st Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Parent/Guardian Phone Number*

Area CodePhone Number
Relationship to Client*
2nd Parent/Guardian

First NameLast Name
2nd Parent/Guardian Date of Birth

MonthDayYear
Date
2nd Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent/Guardian Phone Number

Area CodePhone Number
Relationship to Client
Who Has Custody of this Child?*
How would you like to receive appointment reminders?*

TextVoicemailNone
At what number would you like to receive appointment reminders?*

Area CodePhone Number
Emergency Contact (Other than Parent/Guardian)*

First Name Last Name
Relationship to Client*
Emergency Contact Phone Number*

Area CodePhone Number
Insurance Information
Primary Insurance Name*
Effective Date
Policy Holder's Name*
Policy Holder's Date of Birth*

MonthDayYear
Date
Policy Number*
Group Number
Insurance provider contact phone number on back of insurance card*

Area CodePhone Number
Secondary Insurance (if Any)
Secondary Insurance Name
Policy Holder's Date of Birth
Effective Date
Policy Holder's Name
Policy Number
Group Number
Authorization for Treatment

I consent to the occupational therapy treatment necessary for the below named client.

HIPAA Consent

I give this practice consent to use or disclose the client's protected health information to carry out their treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews. I have been informed that I may review the practice’s Notice of Privacy Practices for a more complete description of uses and disclosures before signing this consent. I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.

I understand that I have the right to revoke this authorization, in writing, at any time.

Mandatory Reporting Agreement

I understand that in accordance with Idaho law and in compliance with the Occupational Therapy Code of Ethics, Journey Pediatric Therapy's providers are mandated reporters. This requires providers to report any concerns of abuse or neglect observed or learned about from our clients or our clients’ parents/caregivers. Mandatory reporting involves filing a report, typically through a phone call to Idaho Child and Family Services.

No Recording Policy

I agree to no electronic recording of these occupational therapy sessions without written permission of all parties involved.

Therapy in Groups

If the therapist deems it therapeutic, I agree to therapy provided in a group setting with Journey Pediatric Therapy. There will always be a 1:1 therapist to child ratio in these groups.

Payment/Insurance Authorization

I authorize for all insurance payments to be made directly to Journey Pediatric Therapy PLLC 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 also understand that if my balance exceeds $500.00 that occupational therapy services may be put on hold until the balance is resolved.

_______________________________________________________________

I have read and fully understand the above consent for treatment, release of medical information, and payment/insurance authorization. I have read and agree to the cancellation policy as described above.

I request that payment under the medical insurance program be made to the provider named below on any bills for services furnished to me.

Provider’s Name and Address:

Journey Pediatric Therapy PLLC

P.O. Box 30071

Spokane, WA 99223

Phone: 208-627-8615
Child (Client's) Name*
Child (Client's) Date of Birth*
Name of Parent or Guardian*
Parent/Guardian Date of Birth*

MonthDayYear
Date
Relationship to Child*
Date*
Signature of Responsible Party*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Child (Client's) Name*
Informed Consent for Telehealth Services

I understand that telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Journey Pediatric Therapy providing occupational therapy services to me via telehealth as mutually agreed upon by the therapist and me. Telehealth may be used in situations where face-to-face therapy is impractical or impossible due to, but not limited to, weather conditions or illness.

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. I understand that telehealth sessions can only take place over a secure platform that is also Health Insurance Portability and Accountability Act (HIPAA) compliant.

I hold Journey Pediatric Therapy harmless for any information lost during a telehealth session due to technical failures.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my/my child’s right to future care or treatment. I may revoke my consent in writing at any time by contacting Journey Pediatric Therapy, P.O. Box 30071 Spokane, WA 99223. As long as this consent has not been revoked, Journey Pediatric Therapy may provide occupational therapy services to me via telehealth as mutually agreed upon without the need for me to sign another consent form.
Child (Client's) Date of Birth*
Name of Parent or Guardian*
Date*
Signature of Responsible Party*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Appointment Cancellation/No-Show Policy

At Journey Pediatric Therapy, our therapists work hard to see each client at their scheduled time. When an appointment is scheduled with us, we set aside enough time to provide the highest quality of care to each client.

Guardians/Parents/Clients will be provided with a warning and may be assessed a $60 fee, if any of the following occur:
- Failure to contact or notify client’s therapist at least 24 hours in advance, via text or phone call to cancel or reschedule a scheduled appointment.
- Failure to attend a scheduled appointment (no-show).
This fee will be charged to the client and will not be billed to the insurance company. The fee will need to be received prior to the client’s next scheduled visit.

If a second no-show appointment or late cancellation occurs within three months, the client may lose their regularly scheduled appointment time. They may be offered the chance to continue therapy on an as-available basis or may be dismissed from Journey Pediatric Therapy occupational therapy services.

We understand there are times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment at the last minute. If you should experience extenuating circumstances, please contact our office at 208-627-8615 or contact the client’s therapist to discuss the situation.

By signing below, I acknowledge that I have read and understand this policy.
Patient Name *
Date*
Patient (parent/guardian) Signature*

Clear
Should be Empty:

Initial Intake Form

Family Information

Insurance Information