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  • New Patient Intake

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  • Insurance Information

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  • Patient Medical and Social History

    This helps us get to know your unique child and family to better serve you

  • Developmental Milestones

    At what age did your child begin the following activities:

  • Self Help Skills

    This lets us know how your child is developing at home in everyday activities

  • Academic History

    Please answer questions under the label that fits your child's age and academic status (birth-3, preschool age, or school age).

  • Consent to Treatment, Consent to Release Reports to Referring Physician, Consent to Release Information to Insurance Billing

  • 1) I authorize Meaningful Movement LLC and staff to provide care which they deem beneficial to my child including services of evaluation and direct care treatment. Furthermore, I understand that Meaningful Movement LLC and staff has promised no specific outcomes as to the services provided by them. 2) I authorize Meaningful Movement LLC and staff to conduct re-evaluations for my child as they deem necessary and reasonable within the scope of their practice and treatment plans. 3) I authorize Meaningful Movement LLC and staff consent to release any or all pertinent medical information to the referring physician and any additional physicians listed below to maintain quality of care. 4) I authorize Meaningful Movement LLC to release information and medical records to insurance providers to coordinate payment of benefits. I understand that these records may be requested at any time by insurance carriers and will be produced for them on my behalf by Meaningful Movement LLC without my prior notification.

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  • Patient Pick-Up Authorization

    If you drop your child off for their therapy session and you'd like for someone else to pick them up
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  • Photography Authorization

    For marketing and to share information/progress with parents

  • I, , parent/guardian of authorize Meaningful Movement LLC to obtain and publish photographs during therapy of my child used for print, online, and video-based marketing materials. I understand that protected health information regarding my child will not be included in any authorized images or materials.
    I hereby release and hold Meaningful Movement LLC harmless from any reasonable expectation of privacy or confidentiality for my minor child or myself associated with images obtained for marketing purposes. Further, I attest that I am the parent or legal guardian of the patient listed below and that I have full authority to consent and authorize Meaningful Movement LLC to use his/her likeness and name.
    I further acknowledge that participation is voluntary and that neither I nor the minor child will receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.
    I hereby release Meaningful Movement LLC and any third parties involved in the creation or publication of company publications, from liability for any claims by me or any third party in connection with the participation of the minor child listed below.

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  • Financial Responsibility/Insurance Disclosure

  • I,* , parent/guardian of,* authorize Meaningful Movement LLC to bill my insurance and receive direct payment from my primary insurance as well as my secondary insurance companies so that Meaningful Movement LLC will be reimbursed for services rendered.

    I understand that I am financially responsible for any fees not paid or covered by my insurance providers.

    I also acknowledge that I am responsible for co-pays, co-insurance and deductibles which are included as part of my insurance contracts.
    1) Any co-pays are due at time of service
    2) Deductibles will be due at time of service
    3) Remaining balances (co-insurance and services not covered by your insurance) will be billed to you after insurance has been billed.

    It is my responsibility to inquire and understand my insurance policy(s) and communicate these policies with Meaningful Movement LLC when coverage changes occur.

    The quoted benefits from your insurance company are not a guarantee of payment coverage. Should you need the detailed information about your coverage, please contact your insurance company directly.

    Currently my coverage is reported by my insurance company as follows:
    1) Co-Pay   *   
    2) Deductible   *   
    3) Co-Insurance   *   

    Private Pay
    I understand that if I do not have insurance coverage or if Meaningful Movement LLC does not accept my carrier, the Private Pay Costs will be applied as follows:
    Initial Evaluation or Re-evaluation: $150.00
    Treatment (direct therapy, per hour): $115.00
    Meaningful Movement LLC reserves the right to change these fee rates as they deem fit and will notify parents/guardians of changes.

    By signing this form, I understand and agree that (regardless of insurance status), I am ultimately responsible for the balance of my account for any professional services rendered.   

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  • Therapy Dog Interaction Consent

  • "Honey” is a 6 year old golden retriever that belongs to Bentley Hopper of Meaningful Movement LLC. Honey is a certified therapy dog through Alliance of Therapy Dogs (ATD). 

    Honey underwent 1 public and 2 on-site testing sessions in 2022 to pass her certification and maintains annual requirements to remain in good standings with her certification. Incidents concerning Honey are not likely and there have been none to date. As always, Meaningful Movement LLC strives to keep children safe, provide best practice, and inform parents.

  • I, , parent/guardian, hereby agree for my child, to hold Meaningful Movement LLC as well as Bentley Hopper and her students, volunteers, independent contractors and other participants (“Releasees”) harmless from any and all claims and/or damages (including medical fees and attorney fees) and causes of action of any nature for any and all personal and/or bodily injury or illness, which may occur to myself or my minor child/ren or which may be aggravated or caused by the negligence of others while interacting with Honey.
     
    ASSUMPTION OF RISK: I, individually and/or on behalf of any minor child, specifically assume any and all known and unknown risk of injury or illness, resulting from interacting with Honey, which may include, but is not limited to: zoonotic disease transmission, scratching, nibbling, heavy leaning, jumping, light brushing, and/or licking by Honey, and any unknown or known allergic reaction. I agree to abide by Bentley’s office policies and procedures as they specifically relate to Honey and her participation as a therapy dog. If I have any questions as to conduct that is appropriate when interacting with Honey, I agree to ask Bentley before engaging in such conduct. I take full responsibility for my welfare and safety as well as for my minor child; and I hereby give permission for emergency medical treatment to be administered as deemed appropriate.
     
    I, individually, and/or on behalf of my minor child, being informed of the known risks, and acknowledging other potential unknown risks, have read the above waiver, and release. I understand that by signing this Agreement I, individually, and/or on behalf of my minor child am waiving certain legal rights

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  • Attendance Policy

    Please feel free to 'screenshot' or take a photo of our attendance policy for your records

  • Here at Meaningful Movement, we are happy to work with you and your child to provide services that maximize your child’s potential and occupational functioning. Frequent and timely attendance of your child’s therapy sessions help to ensure that your child sees the most progress in their performance. Therapy spots are limited, and to respect and best serve the children and families that require services, spots are reserved for individuals who attend scheduled sessions.

    Here at Meaningful Movement, we understand that life happens and you will not be able to attend every appointment. The following policy is in place to secure therapy times for those dedicated to attending while showing grace to life circumstances:

    Late policy: If your child is more than 10 minutes late to a scheduled session, Meaningful Movement reserves the right to refuse that treatment session If you are 10 or more minutes late to three (3) scheduled sessions, you may be discharged at therapist’s discretion.

    Cancellation policy: Session cancellations require a minimum of 24 hours notice aside from emergency situations (sickness or family emergency). Please give as much notice as possible so we may serve someone else during that time.

    If three (3) scheduled sessions (evaluation or treatment) are missed or cancelled outside of the minimum requirement without notification, Meaningful Movement may discharge your child. All scheduling is on a first come, first served basis. We understand that both your schedule and our schedule can change, and we will do our best to accommodate any changes that arise. By signing, I understand that Meaningful Movement LLC have the right to discharge my child from services according the policies listed. Recommendations to other service providers may be made upon request.

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