SENSATION STATION CLIENT INTAKE FORM

I agree to give at least 24 hours notice when cancelling a set appointment.  I will make an effort to re-schedule the appointment or schedule a telehealth visit depending upon availability.  In the event that I do not give this advanced notice, I agree to pay at $50.00 surcharge or cancellation fee.  In the case of an illness or emergency ONLY, I will notify SENSATION STATION as soon as possible and make arrangements to reschedule the appointment.

If I miss three consecutive appointments in a row, I forfeit my standing appointments and I will have to call weekly in order to schedule my appointment.  If 75% of scheduled appointments are missed in any given month, dismissal from therapy may result.

I further acknowledge that if I arrive late for my scheduled appointment time, SENSATION STATION may not be able to accommodate the total treatment time and charges for the pre-scheduled therapy time will be billed in full.  We realize that circumstances beyond our control do come up at times, and would like to establish a solid relationship with your child.

Payment for therapy and educational services provided (including co-pays, co-insurance and deductibles) will be due upon receipt of service. If payment cannot be made within 5 business days, SENSATION STATION must be contacted so that arrangements can be made. We will work with parents to formulate a payment plan that makes access to our services affordable. Failure to pay a bill may result in suspension of therapy or educational services as per our policy.

Please be advised that an evaluation is required prior to treatment. The fee for the evaluation is based on the time it takes for the therapist to evaluate and develop a written report and treatment plan. If we are billing your insurance, we will accept their allowable rate. A referral may be required by your insurance company. Our billing department will notify you if a referral is required. Please sign below to give consent to evaluate your child.

I, understand, certify that I (or my dependent) have insurance coverage and assign all insurance benefits (if applicable) directly to SENSATION STATION GUILFORD INC.

I understand that I am financially responsible for all co-payments, co-insurance payments or deductible payments noted as patient responsibility on the insurance explanation of benefits (EOB).  I hereby authorize the doctor to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all insurance submissions.  I authorize the use of this signature to release medical records to primary physician and or health insurance company.