RS Goldring Intake Form

Talk It Up with RS Goldring Inc.

Thank you for choosing RS Goldring Inc to help you with your Speech and Language needs. To help us prepare and conduct a thorough evaluation, we would like for you to fill out the following information.

Please be as accurate and specific as possible. The information stated here will be completely confidential.
Date:

MonthDayYear
Date
Child's Name:
Child's Social Security Number:
Date of Birth:

MonthDayYear
Date
Sex:*

MaleFemale
Address:
Primary Phone Number:
Emergency Phone:
Father's Name & Place of Employment:
Mother's Name:
Place of Employment:
Public school child is zoned to attend:
Child's Current School:
Child's Doctor:
Phone Number:
List names and ages of siblings if applicable:
How did you hear about us/who referred you:
Description of the problem:
Does your child currently receive any other therapies?

YesNo
If so, please list:
Have you seen a Developmental Pediatrician:

YesNo
If so, who?
When?
*If not, please ask us who we highly recommend currently.
Health of mother during pregnancy:
2. Length of pregnancy (months):
Length of labor (Hours):
History of miscarriage:

YesNo
4. Abnormal circumstances of complications during pregnancy and delivery:
5. Child's weight at birth:
Pounds:
Ounces:
6. Health and/or feeding problems during the first month?
1. Does your child have a history of ear infections?

YesNo
If so, when
2. Has your child ever had ear tubes?

YesNo
3. List any major injuries:
4. Is your child currently taking any medication(s)?

YesNo
If so, please list medications/dosages:
5. Has your child been diagnosed as having an exceptional problem? (i.e. Autism Spectrum Disorder, Down's Syndrome, Cerebral Palsy, etc)
PHYSICAL DEVELOPMENT:
List ages at which:
Sat alone:
Crawled:
Walked:
Fed Self:
Toilet Trained:
Dressed Self:
Does child's development seem unusual when compared to other same-aged peers?

YesNo
SPEECH AND LANGUAGE DEVELOPMENT:
1. List ages at which child spoke:
First words (months):
Short phrases (months):
First sentences (months):
2. Dominant language:
Any other language(s) spoken:
3. At what age was a speech difficulty noted?
By whom?
4. Is child aware of the problem?

YesNo
5. Is child understood by others?

YesNo
6. Is there a history of speech-language/hearing problems within the family?

YesNo
7. Does child have a hearing impairment?

YesNoUnsure
8. Check any of the following which you consider to be problem areas at this time:

Incorrect pronunciationPoor comprehensionSlow in learning new wordsRepeats or hesitates when speakingDifficulty being understoodTalks very littleTalks too rapidlyTalks too slowlyUses incorrect grammarPerseverates on specific words
Other? If so, please describe:
BEHAVIOR:
1. Check any of the following that describe your child's behavior at this time:

ShyOverly talkativeTemper tantrumsNervous, anxiousPlays aloneDoes not like affectionOverly activeWithdrawnShort attention spanRestless sleeperPoor eye contactRepetitive behaviorDemands attentionCries easilyUnusual fearsBehavior problemsSucks thumbSlow learner
Other? If so, please describe:
INSURANCE INFORMATION:
Subscriber's Name:
DOB:
Primary Insurance:
Policy #:
Group #:
Mailing Address:
Secondary Insurance:
Policy #:
Group #:
Mailing Address:
Medicaid:

YesNo
Medicaid #
Notice of Our Privacy Practices:
In 1996, the Federal Government established uniform privacy and security standards to protect patients’ medical information. The standard is known as the Health Insurance Portability and Accountability Act (HIPAA). The deadline for compliance is April 14, 2003.

The purpose of this notice is to ensure that you (the health-care recipient) or your designated representatives are aware of your rights to ensure the privacy of your healthcare information. RS Goldring Inc. retains the right to update this notice at any time. To obtain the most recent notice, please submit a request in writing to the Privacy Officer of RS Goldring Inc.

1. Privacy of the Patient Information

We have created a record of the services and treatment that you receive through RS Goldring Inc. The privacy of your medical information is important to us and we are committed to protect it. We are required by law to keep your medical information private and notify you of your legal rights and privacy practices.

2. Uses and Disclosure of Patient Information

Your medical information will be used for treatment, payment, and operations to maintain the highest quality of care possible. HIPAA allows disclosure of this information to your designated/authorized next of kin, licensed healthcare providers involved in your care, and other healthcare entities including insurance companies, state, and federal regulation agencies, as well as law enforcement agencies in the interest of public safety. If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process. Any other uses and disclosures of your personal health information will be made only with your written authorization. You may revoke such authorization in writing, and we ate required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You, the patient, however, reserve the right in writing restrictions on certain uses and disclosures.

In addition to the above entities, RS Goldring Inc. may communicate with the following persons on my behalf for treatment and my health conditions: for example: Treating Physicians, Therapists, Billing Service Provider, School System.

3. Your rights regarding Medical Information About You

You have the right to inspect and copy your personal health information kept on file with RS Goldring Inc. You have the right to amend information we have about you that is incorrect or incomplete. You have a right to request restrictions on the medical information we use or disclose about you for treatment and payment. You have a right to an accounting of disclosures we made of medical information about you. All of the above request may be submitted in writing to the Privacy Officer of RS Goldring Inc. at the address listed above.

4. Patient's (or Designee's) Personal Communication

You may communicate confidential information, including services, to me by the following means:
U.S. Mailing Address:
Telephone Number:
Fax Number:
Email:
example@example.com
Relationship to Patient:
Patient's Name:
Date of Birth:

MonthDayYear
Date
Parent / Legal Guardian:
Parent / Guardian Signature:

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Date:

MonthDayYear
Date
5. Patient’s Access to Medical Information

You have the right to see and obtain a copy of your medical records at any time. You may request changes to your health information and request the reason for any disclosure (not including treatment, payment, and healthcare procedures).

If RS Goldring Inc. does not agree with your changes, you must be allowed to insert a statement of disagreement into the record. RS Goldring Inc. is not required to agree to your requested restrictions. However, if we agree, the restriction is binding.

6. Confidentiality of Patient Information

RS Goldring Inc. will attempt in all cases to preserve the confidentiality of all oral and written medical information. This includes progress information at the end of treatment sessions, written information and electronic transmission of information to physicians, insurance companies, state and federal entities, and law enforcement agencies in the interest of the public safety. Therapy Steps, Inc. will not be held responsible in the event of natural disaster, theft, or burglary of their physical or electronic property, having taken reasonable precautions.

7. How to File a Complaint

You may file a complaint if you feel that your privacy rights have been violated. RS Goldring Inc. will not retaliate against you if you file a complaint. You may file a formal, written complaint with us at the address below, or with Department of Health & Human Services, Office of Civil Rights, in the Event you feel your privacy rights have been violated.

8. RS Goldring Inc. Contact Information

You may contact Robin Goldring, the Privacy Officer of RS Goldring Inc., for more information on our privacy policy at the below address and telephone number.

RSGoldring Inc.

3050 Royal Boulevard South, Suite 105

Alpharetta, GA 30022

Phone: 1-678-960-9634

Fax: 1-678-960-9634

info@rsgoldringinc.com

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(877) 696-6775 (toll-free)
Acknowledgment of Receipt of Privacy Practices:
I (Name of parent or legal guardian)
on behalf of (Child's Name)
have received a copy of RS GOLDRING INC.’s Notice of Privacy Practices with an effective date of April 14, 2003. I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information:
Name of Patient:
Address of Patient:
City:
State:
Zip Code:
Signature of parent or legal guardian:

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Attendance Policy:
24-hour notice for a canceled appointment is required so our therapists can adjust their schedule accordingly. We have a waiting list of patients hoping to be seen as appointments become available, so please give as much notice as you possibly can. We understand that emergencies can happen, and patients can become sick at any time. We simply ask that you contact your therapist as soon as possible for these emergency situations to avoid any missed appointment fees. You may also contact the business office at the number above. Canceled appointments can be rescheduled upon therapist discretion.

If our office does not receive 24-hour notice for a non-emergency canceled appointment, a $30 fee will be charged.

The Board of Health considers the following signs to indicate communicable disease/illness:

Vomiting

Fever over 100 degrees

Diarrhea

Sore throat

Rash /Swelling Red, or running eyes

Please be sure your child is symptom free for 24 hours before resuming therapy.

Late Policy:

Our therapist’s time is very valuable, and the duration of therapy sessions are catered to your child’s needs. Please arrive on time for your appointment. Contact your therapist directly if you are running late to your appointment. Patients arriving late to an appointment will receive services up until their scheduled session time. This will still incur charges as an office visit and co-pays required by insurance policies.

Thank you in advance for your help and consideration.
Email:
example@example.com
Parent/Guardian Signature:

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Child's Name:
Should be Empty:

PHYSICAL DEVELOPMENT:

SPEECH AND LANGUAGE DEVELOPMENT:

BEHAVIOR:

INSURANCE INFORMATION:

Notice of Our Privacy Practices:

Acknowledgment of Receipt of Privacy Practices:

Attendance Policy: