Therapy and Learning Center of Georgia Intake Form

Consent Form
Name of Patient*

First NameLast Name
This form must be completed before services can be initiated. If the client is under the age of 18 years, all legal guardians must sign the form.

Consent for Treatment: I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at Therapy & Learning Center of GA. I understand that I may terminate these services at any time.

Consent to Communicate with Insurance Company: I give consent to Therapy & Learning Center of GA and its employees/agents to communicate with my insurance company and to release any health information needed in order to authorize visits and collect payment.

Receipt of Policies and Procedures: I hereby attest that I have received a copy of Therapy & Learning Center of GA’s Policies and Procedures, including payment policies, and have read, understood, and consented to be bound by its content.

Receipt of Patient’s Rights: I hereby attest that I have received a copy of the Patient Rights notice, have read, and understood its content.

Receipt of Privacy Policy and Consent for Disclosure of Health Information: I have been provided a copy of Therapy & Learning Center of GA’s Note of Privacy Policies detailing how my Medicaid record may be used and disclosed under Federal and State law. I understand that as part of the Therapy & Learning Center of GA’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity (i.e., insurance, emergency, etc, and I consent to such disclosure for these permitted uses, including disclosures via fax and email only to appropriate parties. I fully understand and accept the terms of this Consent and acknowledge the receipt of the Privacy Notice. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I understand that by refusing to sign this consent or revoking this consent, Therapy & Learning Center of GA may refuse to treat me. I further understand that Therapy & Learning Center of GA reserves the right to change its privacy policies and will provide me with a copy of any revised notice.

I acknowledge that if I elect service time beyond what my insurance company will cover that I am voluntarily paying for that service time.

Photocopy Authorization: I permit a photocopy of this consent form as if it were an original executed consent.
Consent to Treat Signature*

Clear
Printed Name*
Relationship to Patient*
Date*

MonthDayYear
Date

ABA Specific Policies
If you selected NO regarding recieving ABA services please continue on to the next page.
These policies are specific to our ABA services. The standard Policies & Procedures still apply. There is a 24-hour cancellation and rescheduling policy. A $50 cancellation fee will be charged on your credit card on file for no shows and last-minute cancellations. In the case of a child’s illness, cancellations will be accepted before 7:45 am. This includes school visits. Please do not count on your child’s school to notify Therapy and Learning Center of GA.
Parent Responsibilities
Parents are responsible for the following:

Notifying TLC GA and the therapist if the child is unable to attend a session in a timely manner.

info@tlcgeorgia.com 678-824-2145 ext 109

Your child’s Clinical Administrator

Providing appropriate food and drink for the child, if applicable.

Providing appropriate clothing and change(s) of clothing, if applicable.

Attending parent training sessions. This is a MANDATORY insurance company requirement. Insurance coverage will be lost if parent trainings do not occur at least x1 per month.

Providing adequate diapering supplies to the therapist, if applicable

Providing an Emergency Contact and updated medical information.

TLC is committed to the therapeutic process and as such, maintains policies for child and parent attendance in services.

Please initial below acknowledging and agreeing to follow the policies for child and parent attendance in services.
Children who receive ABA services must attend 90% of ABA treatment hours every month and parent training is mandatory at least once per month.
Therefore, if a child is scheduled to receive 30 hours per week and misses more than 10% of their hours in the month (or 2 days per month) the BCBA will meet with the parent to problem solve and discuss any potential necessary changes. A second month of continued excessive absences will result in creating a written plan with the family, and 3rd month of not meeting hours will result in discharge from services.
TLC hires and trains therapists specifically for your child. Therefore, if you are more than 30 minutes late and we are unable to get in touch with you, we will determine that your child is not coming to therapy and send your therapist home.
At times a child’s behaviors require specialized medical attention rendering the environment and circumstances unsafe for therapy. If at any time your child’s BCBA determines that it is not safe for your child and therapist to participate in therapy, TLC reserves the right to put services on hold until your child is cleared by a medical doctor for safety and the BCBA determines that it is safe to continue therapy.
TLC reserves the right to put services on hold and/or discontinue services when a child is absent for more than 2 consecutive weeks without prior approval by the BCBA. TLC reserves the right toemploy a Caregiver Action Plan when a patient is consistently late for pick up and drop off. The plan will be implemented when the child is more than 15 minutes late to pick up or drop off more than 3 times over a 2-week period without contacting TLC the day prior to inform of a late arrival or pick up. The caregiver action plan will ask parents to be on time consistently for 30 days. If the parent is not able to meet the requirement, of bringing or dropping off the child on time (within 15min of the scheduled time) with no more than 2 late days, the child will be dismissed from services.
Toileting
Therapists who assist children in using the toilet will leave the door ajar; however, children will not be in plain view of others to protect patient dignity. Therapists will refer to children’s genitals by the anatomically correct term.
Diapering
If required for your child, all diapering will take place in an area designated by the parent with the door left open/ cracked. Parents are responsible for having diapering supplies available to the therapist. If adequate supplies are not available, the therapist will notify the parent and BCBA and terminate the session.

Therapists will follow these steps when diapering a child: Lay child down on changing surface, careful to minimize contact with the child if his/her outer clothes are soiled. Staff will remove diaper/pull-up and any soiled clothes. Clean the child with disposable wipes, making sure to wipes from front to back. Staff must place soiled diapers/pull-ups and wipes in a plastic bag and place them in the trash. Soiled clothing must be placed in a plastic bag. Place clean diaper/pull-up on child. Staff will wash their hands thoroughly. Staff will wash the child’s hands.
Sick Policy for Therapy and Learning Center of GA Patient
At the Therapy and Learning Center of GA, the health and well-being of our patients are of utmost importance. To ensure a safe and comfortable environment for all, we have implemented the following sick policy:

1. Vomiting and Diarrhea: If a patient experiences vomiting or diarrhea, we kindly request that they refrain from attending therapy sessions until they have been symptom-free for at least 24 hours without the use of medication.

This policy helps prevent the spread of gastrointestinal illnesses and protects the health of both our patients and staff members.

2. Fever: Patients with a fever of 100.4°F (38°C) or higher are advised to stay home until they have been fever free without the use of fever-reducing medication for at least 24 hours.

Returning to therapy too soon can prolong illness and increase the risk of spreading contagious diseases to others.

3. Rashes: For patients with rashes of unknown origin or those suspected to be contagious, we ask that they consult with a healthcare professional before attending therapy sessions. Depending on the diagnosis, a doctor's note may be required before resuming sessions.

This precaution helps ensure the safety and well-being of all patients and staff members while also preventing the potential spread of contagious skin conditions.

4. Lice: In cases of lice infestation, we require that patients complete appropriate treatment as recommended by a healthcare professional before returning to therapy sessions. We also advise informing our staff of any lice infestation for precautionary measures.

Parents or guardians are responsible for informing the Therapy and Learning Center of GA staff if their child is experiencing any of the above symptoms. Our staff will maintain confidentiality regarding any health-related information provided. We appreciate your cooperation in adhering to these guidelines to maintain a healthy environment for all patients and staff members.

Each child must have an Emergency Contact and Medical Information form on file. It is necessary that accurate, up to date information be on file for each child. Should a change occur in telephone numbers, doctors or the person to call in case of an emergency, please notify your BCBA and the clinic immediately to update this information.

By signing below, I acknowledge and agree to follow the policies and procedures and understand that failure to comply with these policies and procedures may result in disciplinary action, including termination of services for my child.
Signature

Clear
Signature
Date

MonthDayYear
Date
Relationship to Patient

ST/OT Policies and Procedures
If you selected NO regarding recieving Speech, Feeding AND Occupational therapy please continue on to the next page. If you selected YES for any of those please fill out the below policies before continuing to the next page.
Appointments:
Please arrive at the appointment 5 minutes early. In the event that you arrive late for your appointment, the appointment may be shortened due to time constraints. If you must cancel an appointment, please call the office immediately.

There is a 24-hour cancellation policy. Please cancel appointments scheduled for the following day before 8pm the evening prior via email or phone. The full-service fee will be charged for no shows and last-minute cancellations. In the case of a child’s illness, cancellations will be accepted before 8 am. This includes school visits. Please do not count on your child’s school to notify Therapy & Learning Center of GA.
I understand that TLC has a 24-hour cancellation policy. Appointments cancelled outside of 24 hours without a doctor’s note will count as a late cancellation and I will be billed the full session fee which is the negotiated rate of my insurance company.
If your child is seen at school, notify the office of any days your child will be unable attend his or her appointment for ANY reason. This includes, but is not limited to, the following: field trips, class parties, plays, concerts, field day, exams, or any other school sponsored activity or event. Schools do not inform us of these days, if we are not notified, the missed appointment will be counted as a no show or late cancellation.

Patients are required to attend 75% of all sessions. In the event that attendance drops to 50% over 2 months, we reserve the right to forfeit your child’s space. After 3 no show appointments (no call, no email, no text) for any reason, we reserve the right to forfeit your child’s space.
I understand that if I no show/late cancel 3 appoints in a row, TLC has the right to dismiss my child from services
If my child’s appointment is on a Monday I agree to cancel on the Friday before or this appt will count as a late cancellation
Fees:
Verification of insurance is not a guarantee of payment. In the event that your insurance does not pay for service, you will be responsible for the fee. It is your responsibility to let us know if your insurance changes. If you do not let us know and we do not have authorization for treatment from the new company, they may not pay and you will receive a bill.
I understand that TLC bills insurance as a courtesy, however; I am financially responsible for my child's therapy bill.
A schedule of fees can be obtained from our website. For greater detail on our fees, please see our “Payment Policies and Client Financial Responsibility” page.

Schools: There is a $10 travel fee when therapists see clients at school.

Times: As per the consent form, if you elect to a service time that is beyond what is covered in your insurance, you are voluntarily agreeing to pay for the extra time as per your insurance’s adjusted rate.

Text messages: I agree to receive and/or send text messages regarding appointments and general information pertaining to services at TLC.
Payment Policies and Client Financial Responsibility
Therapy & Learning Center of GA requires payment for services on the day the service is rendered before the appointment. If payment cannot be provided, Therapy & Learning Center of GA reserves the right to cancel the appointment. Credit cards, checks, and cash are accepted methods of payment. We also accept FSA and HSA cards.

Prior to service, Therapy & Learning Center of GA will verify a client’s insurance coverage. Verification of benefits is NOT a guarantee of payment or coverage. Insurance companies can, and do, deny services even when the insurance verification process says that the service is covered.

As a courtesy service, Therapy & Learning Center of GA will submit claims to the client’s insurance company on behalf of the client when granted permission by the client or the client’s guardian. Therapy & Learning Center of GA

does NOT guarantee coverage or payment from insurance. If the insurance company fails to cover a service or

provide payment for any reason, the client or client’s guardian will be held financially responsible. If claims are

denied, Therapy & Learning Center of GA will file an appeal once. Subsequent appeals are the client’s or client’s guardian’s responsibility. By checking the box below, the client or client’s guardian recognizes and agrees to be responsible for what the insurance company designates as the client’s responsibility.
I understand that, if the client or client’s guardian does not grant permission for the insurance company to be bill, or if the family does not have insurance coverage, they understand they will be responsible for the private pay rates as discussed with office staff.
It is the responsibility of the client or client’s guardian to inform Therapy & Learning Center of GA of any changes to their insurance, including, but not limited to, the following: switching to a new company, changing plans within the same company, and unenrolling from the company.
I understand that if I do not inform Therapy & Learning Center of GA of any insurance changes, I could accrue a larger bill and that I am 100% responsible for this bill.
If an appointment time is selected beyond what is covered by insurance, either by what is allowed in one appointment or the number of appointments allowed within a year or authorization period, the client or client’s guardian is voluntarily agreeing to pay for the extra time as per the insurance company’s contracted rate.

It is our policy that a credit card is kept on file. Clients who are seen at private schools will have this card charged the day of service.
I have the read the above and agree to the following (check all boxes that apply):*

I grant permission for Therapy & Learning Center of GA to bill my insurance company for speech therapy, occupational therapy, and/or ABA therapy. I recognize and agree that I will be ultimately financially responsible for the services renderedI do NOT grant permission for Therapy & Learning Center of GA to bill my insurance/I do not have insurance and understand that I will be responsible for the private pay rates for services as discussed with office staff.
Evaluation and Release of Information Policies
Evaluation reports for speech therapy, occupational therapy, and academic tutoring are generally completed two weeks from the date of the evaluation. There are cases where this timeline must be extended due to other contributing factors. If the timeline needs to be extended, Therapy & Learning Center of GA will contact you.

Once the evaluation report is completed, a hard copy will be delivered to you by the treating therapist at the next appointment. Reports are available via email by request. Please allow 3 business days for this request to be processed. Reports will be password protected with the client’s date of birth.

Clients seen at school will be given an envelope containing the evaluation. The therapist will put the evaluation in the client’s backpack.

Questions relating to the evaluation reports, particularly to the content of the report, should be directed to the evaluating therapist. Please direct scheduling and administrative questions to the office staff.

Therapy & Learning Center of GA CANNOT send ANY medical information to other providers or schools without a proper authorization to release information. If you would like us to communicate with one of your child’s providers, such as a psychologist or audiologist, please inform the office staff so you may complete an authorization to release information.

For clients seen at school, please complete an authorization to release information pertaining to your child’s school AND teacher if you wish for us to coordinate with the school concerning your child’s needs. We will NOT share information you do not permit us to release. An authorization to release information form has been included in this packet for ease – if you require another, please inform the office staff.

If you request information to be shared with another provider, please allow 3-5 business days for the information to be sent. Due to the protected nature of sharing private health information, we cannot immediately send information to another provider.

Medicaid, Amerigroup, Peachstate Patients: Evaluation reports MUST be shared with and signed by the client’s pediatrician (Primary Care Physician) for services to be approved. By signing below, you grant permission for your child’s evaluation report to be shared with his/her pediatrician (Primary Care Physician) by Therapy & Learning Center of GA. You acknowledge that the evaluation report contains private health information that the pediatrician may or may not know. Without this authorization, Therapy & Learning Center of GA will not be able to receive authorization for services.

By signing below, you signify you understand and will follow the above policies and procedures.
Signature

Clear
Signature
Date

MonthDayYear
Date
Relationship to Patient

Permission for Audio/Video Taping/Photos
I allow Therapy and Learning Center of Georgia, to audiotape and/or videotape my child to be used fordiagnostic and/or therapeutic purposes only. I understand all information will be kept confidential

YesNo
Permission To Use Authorized Photos and Videos: I authorize Therapy and Learning Center of Georgia topublish photos and videos of my child for mass print mailings, mass email communication, social media, andTherapy and Learning Center of Georgia website. These photos and videos will be approved by ownership. Iunderstand that I have the option to ask Therapy and Learning Center of Georgia to remove any publishedphotos and videos of my child at anytime.

YesNo
diagnostic and/or therapeutic purposes only. I understand all information will be kept confidential.

publish photos and videos of my child for mass print mailings, mass email communication, social media, and Therapy and Learning Center of Georgia website. These photos and videos will be approved by ownership. I understand that I have the option to ask Therapy and Learning Center of Georgia to remove any published photos and videos of my child at anytime.
Name of Patient
By signing below, you are attesting to the accuracy of the above statements including all consents andauthorizations implied therein. A copy of this agreement is available upon request.
Signature

Clear
Printed Name
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

	1	2	3	4	5/NA
Maintain stable/suitable posture at a table
Drink from a cup
Drink from a glass
Eat with a spoon
Eat with a fork
Cut with a knife
Butter bread
Suck through a straw
Turn on/off faucet
Wash hands
Brush/comb hair
Brush teeth
Take a bath
Put on shirt
Remove shirt
Fasten/unfasten snaps, buttons, zippers
Put on pants
Remove pants

	1	2	3	4	5
Put on socks
Remove socks
Put on shoes
Remove shoes
Tie shoes

	1	2	3	4	5
Does not finish what is started
Cannot sit through a board game
Hums or taps fingers
Takes a long time to settle down
Talks too much
Fidgets or squirms
Is accident prone
Does things in a noisy way
Cannot play quietly for 20 minutes
Cannot keep hands to self
Dawdles
Does things painfully slowly
Must be in control of situations
Must do things own way
Resists being taught how to do things
Resists change in routine
Is overly cautious
Cries for the slightest reason
Hears, but does not seem to listen
Cannot tolerate noisy, busy places
Needs a calm, quiet space to concentrate
Does sloppy work in spite of effort
Is willfully destructive
Does not seem to learn from experience
Cannot tell right from wrong
Worries excessively

	1	2	3	4	5
Complains of boredom
Is overly concerned about performance
Has rapid, unexpected mood changes
Is irritable
Has short fuse, explodes at any little thing
Is insensitive to the feelings of others
Gets into arguments
Provokes adults
Resists authority
Is defiant/belligerent when disciplined
Is stubborn
Ignores directives without arguing
Purposely does the opposite of instructed
Avoids being with peers
Prefers to play with older children
Prefers to play with younger children
Prefers to play with adults
Is physically rough with peers
Is excessively bossy with peers
Gets into fights because of frustration
Resists sharing
Disrupts others’ games/activities
Cannot keep up with peers

	1	2	3	4	5
Engages in rituals
Reacts violently to minor changes in environment
Steals when unsupervised
Steals when supervised
Responds in bizarre ways to normal events
Breaks rules when unsupervised
Breaks rules even while supervised
Shows lack of awareness of location, time, or day
Is reckless; fails to recognize danger

Therapy and Learning Center of Georgia Intake Form

Identifying Information

Insurance Information

Referral Information

Current Therapies

Cultural Considerations

Prenatal/Birth History

Family History

Medical History

Developmental History

Educational History

Consent Form

ABA Intake Form

Client’s Interests

Developmental Concerns

ST Intake Form

Speech and Hearing

Language Development

Parent/Family Preferences:

Feeding Intake Form

Medical Information

Parent/Family Preferences:

OT Intake Form

Functional and Behavioral Questionnaire

Parent/Family Preferences:

ABA Specific Policies

Parent Responsibilities

Toileting

Diapering

Sick Policy for Therapy and Learning Center of GA Patient

ST/OT Policies and Procedures

Appointments:

Fees:

Payment Policies and Client Financial Responsibility

Evaluation and Release of Information Policies

Permission for Audio/Video Taping/Photos