Patient Intake Form 2023

First Name*

Middle Name

Last Name*

Other name your child prefers to go by:

Preferred Name

Address*

Street Address

Street Address Line 2

City/State

Zip

Sex*

Date of Birth*

Date

Current Age*

Grade in School

Social Security Number

Phone Number

Primary language spoken at home

Primary Guardian Name*

Relationship*

Address Same as Child's

Yes

Address*

Street Address

Street Address Line 2

City/State

Zip

Primary Phone*

Can we text this primary phone number?*

YesNo

Other Phone

Area CodePhone Number

Can we text this other phone number?

YesNo

Email address*

Confirmation Emailexample@example.com

Secondary Guardian Name

Relationship

Address Same as Child's

Yes

Address

Street Address Line 2

City/State

Zip

Primary Phone

Can we text this Primary phone number?

YesNo

Other Phone

Can we text this number:

YesNo

Email address

Confirmation Emailexample@example.com

Does your child have any type of Arkansas Medicaid?*

YesNo

Medicaid Number

Is your child a member of an Arkansas PASSE?

YesNo

Select the PASSE the child is a member of:

Is your child covered by Private Insurance?*

YesNo

Insurance Company

Member ID #

Group #

Employer

Policyholder’s Name

First M Last

Policyholder Social Security Number

Policyholder DOB

Date

What is the Policyholder's relationship to the child?

Who is your child’s Primary Care Physician (PCP)?*

Physician's Address

Street Address, City, State

PCP's phone number

When was your child’s last wellness exam?

Month/year

List all adults living in the home and the relationship to the child

List all children living in the home as well as age and relationship to the child

School/Daycare Name and location

Name of school and city

List any sports or activities the child enjoys

Does your child have a good appetite?

YesNo

Is your child a "picky eater" or seem to not like the texture or consistency of certain foods?

YesNo

If Yes, please explain

Does your child sleep well at night?

YesNo

How many hours of sleep does your child receive per night?

How does your child do in daycare/school? (Grades, behavior, friends)

Was there any history of drug or alcohol use during pregnancy?*

YesNo

If yes, please explain

Were there any complications during pregnancy, labor, or delivery?*

YesNo

If yes, please explain

Was the child born premature?*

YesNo

If yes, what was the length of pregnancy?

Weeks

How was the child’s health at birth?*

ExcellentGoodPoor

If Poor, please explain

Was the child delivered via C-Section?*

YesNo

Other Medical History

List any surgeries or hospitalizations?

Does your child have any significant medical and/or behavioral issues? If so, please describe.

Does your child have any medication or food allergies?*

YesNo

Please list allergies

Is your child currently taking any medications?*

YesNo

Please list any medication your child is currently taking

Permission for emergency medical treatment:

In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.

Signature*

Date*

Date

Printed Name*

Which Therapy service(s) are you interested in your child being evaluated/treated for? (Select all that apply)*

Speech-LanguageOccupational TherapyPhysical Therapy

What are your current primary areas of concern? What issues are you hoping to address through therapy services?*

Have you discussed these concerns with the child's Primary Care Physician?*

YesNo

Has your child previously received any therapy services?*

YesNo

Please select all therapy services your child has previously received.

Speech-Language TherapyOccupational TherapyPhysical Therapy

Where were the services received and for how long?

Why did your child discontinue receiving services?

How did you hear about CME?

I give Communication Made Easy Inc. permission to perform any speech/language, occupational, physical therapy evaluation and/or therapy deemed necessary; bill any insurance including Medicaid/Arkids; release evaluations and therapy documentation to daytime care facility, public schools and the primary care physician as needed.

Signature*

Date*

Date

Printed Name*

Communication Made Easy, Inc (CME) will make every effort to work with our clients regarding obligations for services whether payment may be through insurance, private pay, co-payment, or other agreements.
Assignment of Benefits:
• I certify that the information given by me in applying payment is correct. I hereby authorize payment by my insurance carrier of the benefits, otherwise payable to me, to be made directly to CME, Inc for their services.
• I authorize CME, Inc to release all insurance companies and/or compensation carriers only such as diagnostic, therapeutic, and financial information as may be necessary to determine benefits entitled and to process payment claims for health services that will be provided.
• I understand and agree that I am financially responsible for all co-pays, coinsurance and amounts not covered by my healthcare provider.
• I understand that I am obligated to provide ALL insurance information and must notify CME, Inc immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.

Child's Name*

First and Last Name

Signature*

Date*

Date

Please list any person who has permission to pick up your child from therapy services.

Pickup Person 1

First and Last Name

Phone Number 1

Phone # for Pickup Person 1

Pickup Person 2

First and Last Name

Phone Number 2

Phone # for Pickup Person 2

Pickup Person 3

First and Last Name

Phone Number 3

Phone # for Pickup Person 3

Pickup Person 4

First and Last Name

Phone Number 4

Phone # for Pickup Person 4

From time to time your child may be photographed and/or videotaped during therapy sessions, or due to therapy accoplishments. With your consent, the photographs, video, child's first name, and/or a summary of the child's progress may be reproduced and released for use on the CME website, CME print brochures, and social media platforms such as Facebook and Instagram. The released media/information will be used for advertising purposes and/or to spotlight the hard work and achievements of the children we serve here at CME.

Please choose one*

I DO hereby give permission for my child to be photographed and/or videotaped while attending therapy at CME, Inc., and for their photograph/image, first name, and summary of their progress during therapy to be shared on the CME website, print media, and/or social media platforms.I DO NOT give permission for my child to be photographed and/or videotaped by CME.

Child's Name*

Signature*

Parent/Guardian Name*

Date*

Date

Therapist(s) Name

Location of Services

The CME staff would like to take a moment to thank you for chosing CME for your child's therapy needs. CME, Inc., has a passionate dedication to providing the highest quality therapy services to the children in our area. We ask that all families contribute to our commitment by playing an active role in the therapy process to ensure the best possible outcomes for your child. In order to best accommodate all of our patients and ensure continuity of your child's treatment we ask that you adhere to the following appointment and scheduling policies:

As we are growing, we will try to accommodate any changes to the time or day your child needs to be seen, but it may not be possible right away. When an available spot opens, you will be notified.
Please arrive on time for your scheduled appointment. If you are more than 15 minutes late for your appointment time, your appointment may need to be rescheduled.
For HIPPA reasons, we ask that you stay in the lobby/waiting area during your child's therapy session and not access the restricted areas where therapy is being provided.
If you would like to leave during your child's session, please notify the therapist. We also ask that you return to the clinic 15 minutes prior to the scheduled end of the session.
Please cancel appointments as soon as you know you will not be able to attend. This includes doctor's appointments, vacations, illnesses, etc. A minimum of 24 hours notice is required for non-emergencies.
In order for your child to get the best possible results out of therapy, it is important to be consistent in keeping appointments. Patients with attendance below 75% will result in your child losing their regularly scheduled appointment time and move to a week to week schedule.
Repeated failure to comply with this attendance and sceduling policy may result in your child being discharged from services at CME, Inc.

We apprciate your cooperation and compliance with our attendance policy. We look forward to working together to help your child reach their full potential.

Child's Name*

By signing below, you acknowledge that you have read and/or received a copy of CME, Inc.'s attendance policy.

Signature*

Date*

Date

Patient Intake Form

Child's Information

Parent/Guardian Information

Insurance Information

PCP Information

Social / Family History

Prenatal / Birth History

Financial Obligation and Acknowledgement

Pickup Permission

Media Release

Attendance Policy