Kid Centered Therapy - New Client Intake Packet (Medicaid)

We Welcome You
Dear parents & guardians,

We sincerely welcome you and your family to Kid Centered Therapy, LLC. We understand that you have made a very important decision in entrusting your child to our team of therapists.

We look forward to getting to know your child and your family and helping them to reach their full potential. Our goal is to provide quality therapy services, educate parents and family members, and inform families of available resources within the community.

We encourage open communication with our families, so please do not hesitate to reach out with any questions, comments, or concerns as they may arise.

We are excited to be joining your child’s team.

Siriporn Cerber, LCSW,BCBA

CEO and Executive Clinical Director

Phone Number: (954) 642-1186

Fax Number: 561-473-9617

Email: siri@kidcenteredtherapy.com

www.kidcenteredtherapy.com

Client Intake Form

This questionnaire is to be completed by the child’s parent or legal guardian so that Kid Centered Therapy, LLC may learn essential information about your child for use in treatment planning. Kid Centered Therapy, LLC will ensure that any information provided by you is kept confidential according to HIPAA guidelines. Please contact KCT Main Office if you have any questions when completing this form.
Demographic/Biopsychosocial Information
1. Today's Date
2. Legal name of child:*
3. Child's DOB:*
Child's gender:
4. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother or Legal Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Relationship to Child
Father or Legal Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
4. Telephone Number:
Please provide best phone number to contact.
Relationship to Child
6. Child's physician's name/location:
7. Child's Primary or Neurologist's name:
8. Child's Primary or Neurologist's phone number
9.Child's Primary/Preferred Language
How did you hear about us?*

Family or FriendInsurance CompanyGoogle SearchSocial MediaDoctor OfficeSchool or daycareOther
Primary Insurance Information
1. PRIMARY Insurance *
Name of Insurance
Primary Insurance Number*
Number from front of insurance card
Browse Files
Please attach copy of FRONT of primary insurance card Cancelof
Browse Files
Please attach copy of BACK of primary insurance card Cancelof
Secondary Insurance Information
1. Secondary Insurance
Name of Insurance
2. Member ID
Member ID from front of insurance card
3. Group ID
Group ID from front of insurance card
4. Policy Holder Name
Name of Policy Holder
5. Policy Holder's DOB

MonthDayYear
Date
Browse Files
Please attach copy of FRONT of secondary insurance card Cancelof
Browse Files
Please attach copy of BACK of secondary insurance card Cancelof

Treatment History
1. History of treatment (Click All That Apply)

Speech TherapyOccupational TherapyCognitive Behavioral TherapyPlay TherapyOther
Name of Provider: blanks Dates of Service Date to Date Type of Therapy
blanksDateDate
blanksDateDate
School/Placement Information
1. School or Daycare name:
Grade:
2. Child's teacher(s):
3. Type of classroom (ex., self-contained):
4. School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. School hours:

Informed Consent For Treatment
Name of Client:
The undersigned acknowledges that Kid Centered Therapy, LLC is providing services to, or for the benefit of the below named client and is requiring, as partial consideration for providing said services, the execution of this Informed Consent for Treatment which is being executed by the undersigned as the natural parent, guardian, or other responsible party for the below-named client/client. The specific terms of this Informed Consent for Treatment are as follows:

•Kid Centered Therapy, LLC is providing services including, but not necessarily limited to behavior analysis or occupational therapy services, behavior assistant services, evaluation, program development, and treatment of the below named client. • Kid Centered Therapy, LLC will provide the aforementioned services in a professional manner and will take every precaution within reason to insure the safety of the client. • The undersigned herby acknowledges the potential risk of inadvertent injury to the client. Kid Centered Therapy, LLC has informed the undersigned that treatment strategies are often play-based or interactive in nature and accordingly, can potentially pose risk of unintended injury to the client. • The undersigned hereby acknowledges the potential risks of injury based on the strategies implemented by Kid Centered Therapy and consents to the same despite the disclosed risks. Furthermore, the undersigned herby waives, on behalf of the undersigned as well as the client, together with the heirs, devisees, or assignees of the undersigned or the client, any and all liability for personal injury, physical, or otherwise, which may be incurred by the client as a result of the provision of services. • The undersigned acknowledges and agrees that the execution of this form, and the promises and conditions as set forth herein, is partial consideration for the provision of services to the client by Kid Centered Therapy, LLC. • The undersigned acknowledges and agrees that if the status of legal guardian should change, they will immediately notify Kid Centered Therapy, LLC, of the name, address, and telephone number of the person who has assumed guardianship of the below-named client • The undersigned acknowledges and agrees that they have legal authority to consent to treatment, release of information, and all legal issues involving the below-named client. Upon request, I will provide Kid Centered Therapy, LLC, with proper legal documentation to support this claim.

By signing below, I verify that I have read and understand the above Informed Consent for Treatment, agree to adhere to it, and wish to have Kid Centered Therapy, LLC provide services and that the provision of services will be contingent upon adherence to this agreement and full participation by the caregiver/guardian. If at any time there is not full participation and cooperation by the caregiver/guardian, I understand Kid Centered Therapy, LLC may terminate services following notice of 30 days. I also understand that I may discontinue services at any time and will be held accountable to pay for services rendered up to that point.
Name of Parent/Legal Guardian

First NameLast Name
Signature of Parent/Legal Guardian*

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Date Signed

MonthDayYear
Date
Name of Client:
Name or Parent/Legal Guardian

First NameLast Name
Signature of Caregiver/Guardian:*

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HIPAA Privacy Rule of Client Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))
I understand that as part of my child's therapy, Kid Centered Therapy, LLC originates and maintains health records describing my child's health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
- a basis for planning my child's care and treatment;
- a means of communication among the healthcare professionals who may contribute to my child's health care;
- a source of information for applying my child's diagnosis and therapy information to my bill;
- a means by which a third-party payer can verify that services billed were actually provided;
- a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.
I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that, as part of my child's treatment, it may be necessary to provide my Protected Health Information to another covered entity. I have had the right to review Kid Centered Therapy’s notice prior to signing this authorization. I authorize the disclosure of my child's Protected Health Information as specified below for the purposes and to the parties designated by me.
Privacy Rule of Client Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))
I understand that:

• I have the right to review this company’s Notice of Information practices prior to signing this consent upon request;
• That Kid Centered Therapy, LLC reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
• I have the right to object to the use of my child's health information for directory purposes;
• I have the right to request restrictions as to how my child's Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that Kid Centered Therapy, LLC is not required by law to agree to the restrictions requested;
• I may revoke this consent in writing at any time, except to the extent that this Kid Centered Therapy, LLC has already taken action in reliance thereon.
Signature of Client or Legal Representative Witness:

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Client/Caregiver's Name:

First NameLast Name
Should be Empty:

We Welcome You

Client Intake Form

Demographic/Biopsychosocial Information

Primary Insurance Information

Secondary Insurance Information

General Information

Medical History

Treatment History

School/Placement Information

PLEASE READ

Release of information

Informed Consent For Treatment

HIPAA Privacy Rule of Client Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

Privacy Rule of Client Consent Agreement