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Thank you for choosing Therapy & Learning Center of GA, LLC. To help meet your child’s needs. We sincerely appreciate this opportunity, and look forward to working with you and your child.

The attached New Client Paperwork packet includes important information about the practice. Please take time to fill out as much information as possible regarding your child’s developmental history, as this information can be vital to the direction of the therapy plan. We understand that these forms can be time consuming however, it is important that we have as much information as possible prior to your visit so that we may provide the best possible service for your child. If your child has any recent evaluations completed by other health professionals (psychologist, IEP, etc, please bring copies of these with you or you may email them to us in advance.

Please see our Policies & Procedures Packet for information regarding payment, insurance, and cancellations.

Amy Squires, M.S.CCC-SLP Speech and Language Pathologist Director of Therapy and Learning Center of GA GA License #: SLP 008235 ASHA Certification #: 12132094

Was the cord wrapped around the client’s neck?

Please check if your child is diagnosed with any of the following. Please indicate when your child was diagnosed and what was the treatment if there was any.

Please write the age at which your child achieved the following:

Please give the approximate age your child achieved the following.

If your child has been enrolled in Special Education services, has an Individualized Education Plan

This form must be completed before services can be initiated. If the client is under the age of 18 years, all legal guardians must sign the form.

Consent for Treatment: I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at Therapy & Learning Center of GA. I understand that I may terminate these services at any time.

Consent to Communicate with Insurance Company: I give consent to Therapy & Learning Center of GA and its employees/agents to communicate with my insurance company and to release any health information needed in order to authorize visits and collect payment.

Receipt of Policies and Procedures: I hereby attest that I have received a copy of Therapy & Learning Center of GA’s Policies and Procedures, including payment policies, and have read, understood, and consented to be bound by its content.

Receipt of Patient’s Rights: I hereby attest that I have received a copy of the Patient Rights notice, have read, and understood its content.

Receipt of Privacy Policy and Consent for Disclosure of Health Information: I have been provided a copy of Therapy & Learning Center of GA’s Note of Privacy Policies detailing how my Medicaid record may be used and disclosed under Federal and State law. I understand that as part of the Therapy Learning Center of GA’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity (i.e., insurance, emergency, etc, and I consent to such disclosure for these permitted uses, including disclosures via fax and email only to appropriate parties. I fully understand and accept the terms of this Consent and acknowledge the receipt of the Privacy Notice. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I understand that by refusing to sign this consent or revoking this consent, Therapy & Learning Center of GA may refuse to treat me. I further understand that Therapy & Learning Center of GA reserves the right to change its privacy policies and will provide me with a copy of any revised notice.

I acknowledge that if I elect service time beyond what my insurance company will cover that I am voluntarily paying for that service time.

Photocopy Authorization: I permit a photocopy of this consent form as if it were an original executed consent.

By signing below, you are attesting to the accuracy of the above statements including all consents and authorizations implied therein. A copy of this agreement is available upon request.