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Pediatric Patient Intake
Please fill out all information below.
For which location are you requesting an evaluation?
*
Marlton
Swedesboro
Collingswood
Telehealth
Contact Information
Date of Form Submission:
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-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Gender
*
Male
Female
Prefer not to Answer
Is there a language other than English spoken in the home?
*
No
Yes
If yes, what other language is your child exposed to at home?
*
What is your child's dominant language (the language your child knows best)?
*
Do you consider your child to be bilingual/multilingual?
*
No
Yes
Are translation services necessary for a caregiver or family member who is present during the evaluation?
*
No
Yes
Primary Authorized Representative Information
Authorized Representative Name
*
First Name
Last Name
Authorized Representative Relationship
Please Select
Mother
Father
Grandparent
Guardian
Parent
Daughter
Son
Sibling
Spouse
Other Relative
Authorized Representative Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Representative Cell Phone Number
*
Please enter a valid phone number.
Authorized Representative Email
*
example@example.com
How did you hear about MJ KIDZ?
I heard from:
*
Please Select
Word of Mouth
Previous/Current Patient
Google
Facebook
Instagram
Physician
Other Medical Professional
Insurance
Preschool
School
Marketing Material
Marketing Event
Other:
We want to thank our referrals! Please be as specific as possible or put N/A:
*
Insurance Information
Would you like to use your insurance, private pay, or our MVP Program for Medicaid Patients?
*
Insurance
Private Pay
MVP Program for Medicaid Patients
Please note that by choosing private pay I cannot and will not be submitting claims to my insurance company directly. Prior to scheduling an initial evaluation, I understand that I will need to receive and sign a Good Faith Estimate for an estimated cost of services.
*
Please note that by choosing MVP Program for Medicaid Patients I cannot and will not be submitting claims to my insurance company directly. Prior to scheduling an initial evaluation, I understand that I will need to receive and sign the MVP form for estimated cost of services.
*
Primary Insurance (Please Select)
*
Please Select
Aetna
Aetna Better Health
Amerigroup
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Horizon NJ Health
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Medicare
Meritain
Tricare
Plan information
*
Primary ID Number
Group Number
Primary Phone Number
*
Please enter a valid phone number.
Primary Effective Date
*
-
Month
-
Day
Year
Date
Primary Subscribers Name
*
First Name
Last Name
Primary Subscriber's Date of Birth
*
-
Month
-
Day
Year
Date
Please upload FRONT of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload BACK of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload drivers license of primary subscriber. If the patient is the primary subscriber, you can upload driver's license of any authorized representative.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have secondary insurance?
*
Yes
No
Secondary Insurance
*
Please Select
Aetna
Aetna Better Health
Amerigroup
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Horizon NJ Health
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Medicare
Meritain
Tricare
United Health Care Community Plan
*
ID Number
Group Number
Secondary Phone Number
*
Please enter a valid phone number.
Secondary Effective Date
*
-
Month
-
Day
Year
Date
Secondary Subscribers Name
*
First Name
Last Name
Secondary Subscriber's Date of Birth
*
-
Month
-
Day
Year
Please upload FRONT of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload BACK of the insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload drivers license of primary subscriber. If the patient is the primary subscriber, you can upload driver's license of any authorized representative.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Care Physician Information
Primary Care Physician Name
*
Primary Care Physician Practice
*
Primary Care Physician Phone Number
*
Please enter a valid phone number.
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Primary Concerns
What are your primary concerns? Please be as specific as possible.
*
Does your child have any medical diagnoses? e.g. Autism, ADHD, Feeding Difficulties etc.
*
Do you have any concerns regarding your child's feeding and swallowing skills?
Yes
No
Concerns regarding picky eating
Concerns regarding choking/gagging
Other
Has your child previously had a speech and language evaluation?
*
Yes
No
Where and when?
*
What were you told?
*
Indicate with a checkmark any items that are difficult for your child:
*
Understanding what he/she hears
Following directions
Imitating Gestures
Imitating Sounds
Speaking in grammatically correct sentences
Answering questions
Pronouncing words correctly
Getting his/her point across
Telling stories
Labeling objects, actions, people
Pre-literacy/literacy skills
N/A
Other
How does your child currently communicate?
*
Vocalizing/Grunting
Pointing/Gestures
Simple Signs (ASL)
Single Words
Sentences
Speech Generating Device (Touch Chat, LAMP, Go Talk, ProLoQuo)
Non Speech Generating Device (picture exchange communication system, choice boards)
Other
Which best describes your child's speech intelligibility?
*
Non-speaking
Limited Vocalizations
Difficult for family to understand
Difficult for others to understand
Easy to understand
Other
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