dreambigtherapies.com

Dream Big Intake Form

This form will take 20-30 minutes to complete. Please be as detailed as possible.
Child's Full Name*

First NameLast Name
Parents Full Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Child's Gender?*
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who does your child primary live with?*
Does your child have any siblings (names and ages)?*
Language(s) spoken at home?*
Select all that apply: What is this evaluation for ?

Physical TherapySpeech TherapyOccupational TherapyFeeding TherapyOMT Therapy
What are your concerns? Reason for an evaluation? Please be as detailed as possible?*
Pediatrician Information
Child's Pediatrician/ Physician*

First NameLast Name
Pediatrician's Clinic Name*
Pediatrician's Phone Number *
Please enter a valid phone number.
Can we share your report with your pediatrician?*
Can we share your graduation, progress notes, and discharge report when applicable with your pediatrician?*
Are there any other professionals you would like us to reach out to (School, OT, SLP, PT, Teacher, Lactation Consultant, Psychologist, etc)? If so, who?*
Insurance Information
Insurance:*

I would like to use my insuranceI would like to be self pay
Name of Policy Holder *

First NameLast Name
Phone Number of Policy Holder*
Please enter a valid phone number.
Date of Birth of Policy Holder*

MonthDayYear
Date
Company of Policy Holder*
Insurance Company *
Policy #*
Group #*
Member #*
Take a photo of your insurance card (front and back) or military ID.
PATIENT FINANCIAL POLICY

As a health care provider our office understands that you as a parent have many choices in providers and we are pleased you have selected our office for your child’s healthcare needs. We are committed to providing quality therapy services to your child. With this commitment we believe a clear understanding of our financial policy is imperative. Dream Big Pediatric Therapies Patient Financial Policy is as follows:
1. For patients with active insurance, families must present your valid insurance card at your appointment. It is required to inform our billing department of any changes to your insurance coverage. It is important to notify our billing department immediately if your insurance information changes. This will allow us to submit claims correctly. Please be aware that if any current or new insurance information is not provided before your appointment and your insurance requires pre-authorization, we will be unable to submit claims. In such cases, any charges for services received due to a failure to provide updated insurance information and obtain necessary pre-authorization will be the patient's responsibility.
2. All families are required to have a valid credit card on file to begin services.
3. All evaluations are billed at a rate of $250, whether to insurance or self-pay.
4. Invoices containing all finalized deductibles or copays are emailed to families on Tuesdays with a payment due by Friday that same week. All families have the option of paying on our parent portal, in person, by clicking the hyperlink in the invoice email, or over the phone. If none of these options are completed by Friday, current balances will be charged to the card on file. Once a payment has been processed, no refunds will be made for the purposes of changing the payment method. Different payment arrangements must be made prior to Friday. If payments on Friday are not processed, therapy sessions must be paused until a payment in full is completed or a payment plan is agreed upon prior to restarting sessions.
5. Dream Big does not determine the amount paid on insurance claims. It is the patient's responsibility to contact their insurance company with questions regarding claim concerns.
6. If no invoice is provided on Tuesday stating a balance, then insurance has not yet processed claims and an email will be sent with balances when insurance has processed.
7. Insurance can take up to 180 days or longer to process claims, which means that multiple claims may be returned at one time. Dream Big Pediatric Therapies has no authority over when or how claims come back. It is the patient’s financial responsibility once claims are processed.
8. For any outstanding balances, a payment plan must be established to pay the balance in full within 6 months from the final invoice.
9. If the balance exceeds $250, all services will need to pause until a weekly arrangement decreasing the balance is agreed upon.
10. There are no refunds for any services provided by our skilled clinicians for any reason.
11. Once insurance is finalized, no discount can be provided in accordance with our insurance contracts.
12. Once claims are finalized, if the family refuses payment by denying access to a card on file, the account will be sent to a third party collection agency. Please refer to the Commercial Insurance Carriers section.
13. If any discrepancies with your statement occurs, it is up to the parent to contact the office manager or billing. If a chargeback occurs, from either a session or cancellation charge from missing an appointment, then the patient is responsible for any financial penalties caused by the chargeback and will be placed on the patient's next Dream Big invoice.
I have read the terms and conditions of the Patient Financial Policy and agree to follow Dream Big Policies and Procedures*

Yes
Evaluation Scheduling

If a family cancels or does not show an evaluation 3 times within a 12 month span, then they will be immediately placed on the "Next day scheduling" in which the front office may call the day before to schedule.
I have read the terms and conditions of the Evaluation Scheduling and agree to follow Dream Big Policies and Procedures*

Yes
Commercial Insurance Carriers: We will submit claims to most insurance carriers when the appropriate information is provided to us. Invoices are sent via email on Tuesdays. Any outstanding balances, copays and/or deductibles are due each Friday. In the event you do not receive an invoice, but have received services, insurance has not yet processed those claims. They have 30-90 days to return claims to us with their payment determinations. Since your policy with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care. It is your responsibility to understand your insurance benefits. If you are not sure if a service or treatment is covered you should contact your insurance carrier. You are responsible for charges not paid by your insurance carrier (which would include any claims denied or any claims not paid in full). If a claim is denied you will need to contact your insurance carrier to dispute the denial or how the claim was processed. If an appeal needs to be filed, the parent will be responsible to file the appeal and all charges will be due in full. Charges will not be suspended while an appeal is being reviewed. If the appeal is approved and benefits are paid, only then will a refund be issued to the patient. If updated insurance is not provided at the time of service, we may not be able to process your insurance claims based on their requirement for preauthorization of services.
I have read the terms and conditions of the Commercial Insurance Carriers and agree to follow Dream Big Policies and Procedures*

Yes
TEIS Financial All TEIS families are required to have an IFSP for TEIS to cover services. Upon receiving a referral from TEIS, completing the Intake form, and providing updated insurance information, there will be no charge to any TEIS families when they are actively a part of the TEIS program If you are a part of TEIS, a card will be placed on file to verify family, with a $1 charge which will be immediately reimbursed at the office at my time of arrival. If a family is no longer a part of TEIS, then they are responsible for services per Dream Big Financial Policy.
I have read and agree to follow the TEIS Financial Outlined (if a part of TEIS)*

Yes
Method of Payment: Our office accepts cash, personal checks, Credit Cards, payments through the patient portal, payments through our emailed invoice, payments over the phone. A $35 NSF charge is incurred for all returned checks. A cash or credit card payment covering the Check plus the NSF charge must be paid within 2 weeks or a bad check will be reported to the local district attorney’s office checks. If services are not paid according to the terms the patient understands that our office reports to an outside collection agency. In the event that your account is turned over for collections, patient agrees to pay all additional fees assessed with the collection of the debt. These fees include collection agency fees and attorney fees.
I have read the terms and conditions of the Method of Payment and agree to follow Dream Big Policies and Procedures*

Yes
Patient Medical History
Any complications (severe stress, shock, accident, bed rest, or health problems) during pregnancy?*

YesNo
If so what?*
How was child born?*

Planned C-SectionVaginal BirthEmergency C-SectionN/A
For the newborn hearing screening did your child PASS or FAIL*
Any medical intervention or labor complications during birth?*

YesNo
If so what?*
Where was the child born(hospital, birthing center, home birth, etc.)?*
What was the child's gestational age?*
What was the child's birth weight?*
Any NICU stay? If so, how long?*
Has your child's hearing been evaluated following their newborn hearing screening?*

YesNo
Has your child's vision been evaluated?*
Has your child's hearing been evaluated following their newborn hearing screening?*

YesNo
If yes, what were the results?*
Child's diagnosis, medical conditions and medical history (current or pending) ex: ADD/ADHD, ASD, Fragile X, Dyslexia, Down Syndrome, Anxiety or Mood Disorders, Sensory Processing , etc.*
Does your child receive any other services (i.e ABA, Occupational Therapy, Physical Therapy, etc.)*
What medications is your child taking currently? Any past medications, if so please list. *
Select all that apply: Does your child have a history of*

IllnessesAllergies- food or environmentalEar InfectionsTubes in earsSkin rashes/problemsGI ProblemsBed wettingRespiratory ProblemsSeizures EpilepsyOral Ties (cheek, tongue, and lip ties)N/A
Is there a family history of delay or any therapies?*

YesNo
If so please explain.*
Infancy and childhood questions.

If your child is not yet at this stage in life, you can leave those portions blank.
Check all that apply in regards to post delivery.*

The child did NOT cry immediatelyThe child not NOT have immediate physical contact with motherIt was NOT a positive bonding experienceThe child DID have feeding difficultiesN/A
Check all that apply in regards to child's infancy. *

The child DID/DOES suck their thumb or us a pacifierThe child DID/DOES have sleeping problemsThe child DID/DOES having difficulty in peek-a-boo, pat-a-cake, or other interactive games.The child did/does NOT tolerate tummy timeThe child DID/DOES have difficulty self-soothingN/A
Is this evaluation for infant feeding?*

YesNo
Has your child had a tongue, cheek or lip tie revision?*

YesNo
If so, when and with whom?*
Select all the apply: Social and Emotional Tendencies*

My child prefers to play aloneMy child does not accept changes in routine easilyBecomes easily frustratedDoes not finish what they startChanges activities frequentlyFidgets or squirmsApt to be impulsive, heedless and accident proneCannot keep hands to selfHas poor self-image and feels worthlessMarked mood variations- tendency toward tantrumsCannot tell right from wrong Is overly concerned about performanceTends to withdraw from groups or new peopleTakes a long time to settle Is generally disorganizedRuns rather than walksCannot tolerate noisy, busy placesN/A
Select all the apply: Movement and Balance*

Has trouble or hesitancy in learning to climb/descend stairsCrawling period absent or very brief (less than 4 months)Did/does not like being placed on stomach as an infantGets car sick frequentlyIs nauseated/vomits from movement experiences (swing, etc)Appears stiff, awkward, or clumsy in movementN/A
Select all that apply: Gross and Fine Motor Skills*

Seems weaker or tires more easily than peersRides a bike/tricycle without training wheelsDislike of coloring or paper/pencil skillsDislikes working puzzlesDifficulty with scissorsSeems to have great difficulty learning new motor tasksDifficulty catching a ballDifficulty kicking a ball Difficulty pumping self on swingDifficulty playing with small manipulative toys (i.e legos, etc.)N/A
Select all that apply: Activities of Daily Living at age appropriate level *

Difficulty bathing (tolerating hair washing, bath time, etc.)Difficulty feeding (using utensils/drinking from an open cup)Difficulty with grooming (tolerating toothbrushing, hair brushing, face washing)Difficulty with dressing (fasteners, turning items right side out, donning/doffing clothes)Difficulty with sleeping (frequent waking, frequent bed wetting, open mouth breathing, etc.)Difficulty with toilet trainingN/A
Social or behavioral concerns?*
School your child attends? What grade is you child in?*
Any academic concerns?*
Is this evaluation for Feeding Therapy?*

YesNo
What is your main concern regarding feeding?*
What foods does your child typically eat?*
Any allergies with food?*

YesNo
If so what foods?*
Is this evaluation for Speech Therapy?*

YesNo
Does your child use gestures and/or words to communicate? Please describe*
Is your child showing signs of frustrations? Please describe*
How much of your child's speech is understood by unfamiliar listeners? 25%,25%, more than 50%. Please provide some examples of your child's speech *
Anything else you would like to share?*
Dream Big Policies and Procedures
Patient Preferences. Select all that apply*

I require my clinician wears an N 95 mask at all times and I would like them to directly get my child from the car at their scheduled time to avoid any lobby waiting area.I require a mask be worn at all times and it does not need to be a N 95, but can be a disposable mask or cloth mask that the clinician wearsI prefer the clear facial shield that cover the clinicians entire face, and a mask is not requiredhave a preference to have the clinician come out to my car for my child's scheduled appointment to avoid waiting in the lobby, I will inform the front office.N/A
I give consent to allow Dream Big employees to provide Band-Aid’s and Ice packs if necessary*

YesNo
I understand that Dream Big will not provide epi pens to my child and I must have my own with me and present incase of emergencies if my child requires one.*

Yes
I understand that if my child is not potty trained that I am required to remain at the building to assist with bathroom needs that may arise. If Toileting needs are a part of my child’s treatment plan I am required to fill out a toileting waiver that I must ask for at the front office.*

Yes
I understand that there are no audio recording or video recordings of the sessions allowed for protection of all clients and privacy. If I wish to record a session I understand that I must email permission to the office manager at manager@dreambigtherapies.com more than 24 hours before my scheduled appointment to determine approval.*

Yes
I have read the Frequently Asked Questions and agree to Dream Big Policies and Procedures that can be found at https://www.dreambigtherapies.com/frequently-asked-questions/*

Yes
DREAM BIG ATTENDANCE POLICY
Consistent Therapy attendance is the only way for our children to progress on their goals and achieve success. We are committed to ensuring your children receive the quality of care and consistency they deserve and require. We want to ensure all children have access to quality therapy. Frequent missed appointments not only limit your child’s success but also limits others’ access to quality consistent therapy. For those reasons, we have developed our attendance agreement for our families attending Dream Big Pediatric Therapies. Our attendance policy is below:
- All families are allowed to miss 2 sessions in an 8 week span and still remain on the permanent recurring schedule. Exceptions can be made with the office manager directly.
- Failure to comply will result in removal from the permanent schedule and placed on a flexible schedule. All frequency recommendations from the current IFSP (if TEIS) will be accommodated to the best of our ability, but permanent time slots will not be provided.
  - If a family has a “no show” (missed appointment without any notice) for two consecutive weeks in a row they will be removed from the permanent schedule.
  - If moved to a Flexible schedule from a permanent schedule, there will need to be 5 consistent and consecutive completed make up sessions in order to be put back onto a permanent schedule.
- The Flexible Schedule follows the same guidelines as a permanent schedule. All families are provided 2 cancellations in an 8 week span. Failure to comply results in removal from flexible scheduling and a family will be put on “same day scheduling” that allows a family to schedule appointments by calling that same day. There will need to be 5 consistent and consecutive completed make up sessions in order to be put back onto a flexible or permanent schedule.
We understand schedules can be busy and we want to support all families, children, and schedules. If a family prefers or is unable to commit to a weekly recurring schedule, Dream Big is more than willing to begin a Flexible Schedule in which the parent and office will schedule sessions at the beginning of the week for the following month or Same Day Scheduling in which the family can schedule an appointment for their preferred discipline that day.
I have read the terms and conditions of the Dream Big Attendance Policy and agree to follow Dream Big Policies and Procedures*

Yes
I pre-authorize Dream Big Pediatric Therapies to use the payment information (debit card and / or credit card) on file to charge for the applicable fees. I acknowledge that I have read and understand the above policy statement . Additional information is available in the Attendance Policy which is available in the medical offices and on www.dreambigpediatrictherapies.com. I may also contact the Billing Department at billing@dreambigtherapies.com for additional information. Please note: Repeated “missed appointments” and “no show” appointments will result in discharge from the practice.*

Yes
Health Insurance Portability and Accountability Act (HIPAA):

The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law,” HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”); the keeping and use of patient records (“privacy rules”); and, storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including private practice therapeutic and health care services. Providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. The information regarding HIPAA was taken directly from the Tennessee Department of Health website. Please read this document as it is important you know what patient protections HIPAA affords all of us. In private practice therapeutic and health care services, confidentiality and privacy are central to the success of the therapeutic relationship; and, as such, we follow HIPAA regulations to protect the privacy of your health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask for further clarification. Nashville Pediatric Specialists is required by law to secure your signature indicating you have received this Patient Notification of Privacy Rights document. I understand and have been provided a copy of Patient Notification of Privacy Rights document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgement form.
YES - I understand the information presented about HIPAA and my privacy required
Liability Waiver

Inconsideration of the risk of injury that exists while participating in therapy, classes, or using materials at the Dream Big Pediatric Therapies building and in consideration of my desire to participate in activities and being given the right to participate in same; I hear by, for myself, my heirs, my executors, administrators, assigns, or personal representatives parentheses (hereinafter Collectively, or, I, or me, which terms shall be also include release or parents or guardian if release or is under 18 years of age) knowingly and voluntarily enter into this waiver and release of liability here by wave and all rights, claims or causes of action of any kind arising out of my participation in the activity and release and discharge my child located at Dream Big pediatric therapies, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, Representatives, predecessors, successors and assigns from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned activity.

I am voluntarily participating in the aforementioned activity, and I am participating in the activity entirely at my own risk. I am aware of the risks associated with participating in classes and therapies, which may include but are not limited to: physical or psychological injury, pain, suffering, illness, disfigurement, temporary, or permanent disability, including paralysis, economic, or emotional loss, and death. I understand that these injuries or outcomes may rise from my own or others negligence, conditions related to the travel to and from the activity or from my conditions at the activity locations nonetheless, I assume all related risks both known and unknown to me of my participation in the activity.

I further agree to indemnify, defend and hold harmless the releases against any, and all claims, suits her actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by me or anyone on my behalf, including attorneys fees, and any related cost.

I further acknowledge that Releases are not responsible for errors, omissions, acts or failures to act of any part or entity conducting a specific event or activity on behalf of Releases. In the event that should require medical care or treatment, I authorize Kelly Speech Pathology LLC DBA Dream Big Pediatric Therapies to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any cost incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I further acknowledge that this Activity may involve a test of a person’s physical and mental limits and may carry with the potential for death, or serious injury.

I hereby acknowledge that I have carefully read this waiver and release and fully understand that it is a release of a liability. I expressly agree to release and discharge, Kelly Speech Pathology LLC DBA Dream Big Pediatric Therapies and all of its affiliates, managers, members, agents, clinicians, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against Kelly Speech Pathology LLC DBA Dream Big Pediatric Therapies for personal injury or property damage. To the extent that statute or case law does not prohibit releases of ordinary negligence, this release is also for such negligence on the part of Kelly Speech Pathology LLC DBA Dream Big Pediatric Therapies, its agents, and employees.

I agree that this Release shall be governed for all purposes by Tennessee law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.

In the event that any damage to equipment or facilities occurs as a result of my or my family's or my agents' willful actions, neglect, or recklessness, I acknowledge and agree to be held liable for any all cause associated with any such actions or neglect or recklessness.

This waiver and release of liability shall remain in effect for the duration of my participation activity at Kelly Speech Pathology LLC DBA Dream Big Pediatric Therapies, during this initial all subsequent events of participation.
I AGREE
Authorization for Treatment:

My signature below is confirmation that I have informed Dream Big Pediatric Therapies of all necessary information and have answered all questions truthfully and to the best of my ability. I authorize the therapists of Dream Big Pediatric Therapies to administer such treatment as is prescribed and considered therapeutically necessary on the basis of findings during the course of treatment.
Client or Parent/Guardian (If minor) Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Dream Big Intake Form

Pediatrician Information

Insurance Information

Patient Medical History

Infancy and childhood questions.

Dream Big Policies and Procedures

DREAM BIG ATTENDANCE POLICY