Kids in Sync Intake Form

Child Development (Current)
What are your primary concerns?*
How would you describe your child's temperament/disposition (e.g happy, calm, friendly, lethargic, energetic, passive, flexible, rigid)?*
Describe your child's play and favorite activities (i.e. prefers to play alone vs. with others, routine vs. exploratory play, sedentary vs. active)*
How does your child socialize with peers or extended family members (i.e. passive vs. active participation)?*
Does your child behave better/worse in a group setting? Describe.*
Describe your child's communication skills*
Is your child toilet trained? Bowel and bladder. Please describe any difficulties.*
Describe any concerns or difficulties with fine or gross motor skills*
Does your child fall, crash, or bump into things (either on purpose or by accident)?*
Describe your child's eating habits (i.e. food preferences, messy eater, small bites). Is your child a "stuffer" (large quantities of food at one time)? Is your child "picky"?*
Does your child demonstrate difficulty with transitions or changes in their schedule?*
Does it take a long time for your child to calm after being upset? If yes, what will usually calm them down?*
What are you hoping to accomplish by this consultation/evaluation?*
Speech Language TherapyOccupational TherapyPhysical TherapyMental HealthOther

Family History

Please indicate if your child or a member of your family has been diagnosed with any of the following

Diagnostic history

Rows	Child	Family Member	Notes
Vision challenges
Cognitive delay
Autism or Autism Spectrum Disorders
Learning disability (e.g. ADHD, dyslexia, dyspraxia). Specify in notes.
Mental illness (e.g. anxiety, depression). Specify in notes.
Psychotic disorders (e.g. schizophrenia, schizoaffective). Specify in notes.
Personality disorders (e.g. borderline, antisocial). Specify in notes.
Trauma or Post-Traumatic Stress Disorder
Postpartum Mood Disturbance (e.g. PP anxiety, PP depression, PP psychosis). Specify in notes.
Substance abuse
Other? Specify in notes.

Please indicate if your child or a caregiver of your child (parent, legal guardian, childcare provider/nanny) have experienced the following:

History of trauma

Rows	Child	Caregiver	Prefer not to share/notes
Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Divorce of parents
Substance abuse of parent
Parent incarcerated
Witness to domestic violence
Significant accident or injury
Natural disaster

Provider Information

Please list names and dates of all consultants who have been involved with your child past or present.

Providers

Rows	May We Contact?	Name of Provider	Address and Phone Number
School
Preschool
Early Childhood
Teaching Assistant
Speech/Language Therapy
Occupational Therapy
School and District
School Speech
School OT
School Social Work
Physical Therapy
Psychiatrist
Psychologist/Social Worker
Managing Physician
Other (Vision, Nutritionist, Audiologist, etc.)

Please attach any relevant reports from previous providers (e.g. neuropsychological testing, mental health evaluation, etc.)

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The following are our policies that govern insurance claims (PLEASE KEEP FOR YOUR RECORDS):

To expedite your child’s care, we will submit claims to BCBS, but cannot guarantee the coverage of your services. You (the parent) of the financially responsible party, will pay all past due portions of your charges not covered by insurance, specified by the insurance. This portion is due in full at the time of receiving your monthly statement. If payment is not received in a timely manner this may affect future appointments with your therapist. Your co-pay is due at the time of your visit.

Please arrive 5 minutes early before your schedule time to sign in and make your co-payment. All insurance information in required claim forms must be complete. If incomplete, we will be unable to appropriately bill the insurance company and the responsibility for payment then becomes that of the insured.

Our office does NOT guarantee that your insurance company will pay on claims. However, if for some reason, your insurance company pays differently than determined at the time of your visit, or your insurance claim is denied, you (the parent/ guardian) are then considered to be responsible for the full amount of the bill. Insurance payments ordinarily are received within 30 to 60 days from time of submission.

If your insurance company has not made payment to our office within 60 days, we request that you (the insured) pay the balance due, and then seek reimbursement from the insurance company when and if it is paid. Our office will not enter into a "dispute" with BCBS over a claim, although we will work with the insurance company to sort any confusions or questions that may arise. If necessary we will request that you contact your insurance company to assist with the resolution of any problems.

Please contact your insurance company in advance to see if they cover the services we provide at our clinic.
Understanding of Insurance Allowance
I understand that my child’s occupational therapy services will be billed directly to BCBS and that I will incur the following cost for services.

I have a family annual deductible of blank that needs to be met prior to to
insurance paying for any services.

I have an individual annual deductible of blankthat needs to be met prior to to insurance paying for any services.

I have a copay of blankto be paid at every session ongoing throughout the year.

I have a co-insurance of blank that is also due to be paid at every session
ongoing throughout the year.

My child is allowedblanksessions during the calendar year for occupational therapy.
I understand that Kids in Sync will charge my credit card on file for all co-payments and co-insurance.
BLUE CROSS BLUE SHIELD

ALL CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE. We are a member of Blue Cross Blue Shield only. You are responsible for verifying that we are an in-network provider under your plan. All patients will be responsible for their co-payments, co-insurance and deductibles as applicable and as long as they have verified with their insurance company that our therapists are in their plan.
I understand the above note regarding BCBS.
Kids In Sync Treatment Policies
We do not allow cell phone usage, pictures, or videos during the evaluation process, or during treatment sessions. If you would like to have a record of your time here, the therapist will have their phone accessible and can make a video available to you*
An evaluation at Kids In Sync does not guarantee ongoing services will be provided by Kids In Sync. If an evaluation at Kids In Sync is performed but ongoing services are not scheduled, I will still be held responsible for payment of services rendered.*
An evaluation at Kids In Sync will result in a series of recommendations made by the clinician that may include but are not limited to: referrals to other clinicians (mental health therapists, vision specialists, neuropsychologists), conditions of therapy to ensure best treatment outcomes and practices, or referrals to other occupational therapy practices who specialize in addressing a need highlighted during the child’s evaluation for treatment. My agreement or disagreement with these recommendations does not negate my responsibility for payment of services rendered*
Limits of Treatment: There are rare circumstances in which a therapist may be obligated to make a unilateral decision to terminate therapy. Such circumstances include, but are not limited to: the current treatment appears to be ineffective; threats are made against the clinician or his/her family; the clinician does not believe they have the necessary training to address a specific problem; or there is a significant therapeutic impasse. In such cases, the clinician will attempt to find a suitable referral. The clinician cannot be responsible as to whether this referral is accepted. I am aware that I may terminate at any time without consequence, but I will still be held responsible for payment of services rendered. Likewise, nonpayment of fees will result in termination of professional services and fee collection for fee services rendered.*
I have read and understand Kids in Sync’s Treatment Policies.
Kids In Sync Sick Policies:

Please do not bring you child to therapy if they have a fever, cough, runny nose, diarrhea, skin rash, or any other symptom of illness.

Please be sure your child stays home and is fully recovered for 24 hours after all symptoms have cleared up before bringing them back to therapy.

Please make your therapist aware if you or your child has a communicable disease (i.e. chicken pox, ring worm, pink eye, strep throat, head lice, etc.)

Also, please do not bring older siblings who are home from school due to illness to Kids in Sync, and if you are sick, please stay home and rest. As you know, adult germs can infect others, too.

We all have a responsibility to protect the people at our clinic. If you bring a sick child to therapy or you come to therapy sick, you risk infecting everyone else. We will have to ask you to go home if you or your child come to therapy sick.
I have read and understand Kids in Sync's Sick Policies.
Acknowledgment of Receipt of Kids in Sync Financial Policy Summary

The parent or legal guardian is responsible for payment. In consideration of services to be rendered, you, as the undersigned parent or guardian, agree to pay Kids in Sync for all services and supplies provided to you at the established rate, including any deductibles, co-payments or other charges, as permitted by third-party prayers. By signing the Financial Summary Policy, you accept responsibility for any costs, including attorney’s fees incurred by Kids in Sync in the collection of these charges for examination, diagnosis and treatment received. Furthermore, you certify that the information given by you for purposes of payment is, to the best of your knowledge, complete and accurate.

Additionally:
At least 72 hours notice is required for copies of medical records and there may be a nominal fee.*
Full payment is due at the time of receipt of your statement for self-pay/out of network clients. If your insurance carrier is BCBS and we do not have your insurance information, we require payment upon receipt of the invoice*
You are ultimately responsible for payment of all services.*
Payment for Consultations and Evaluations are due at visit for self-pay clients*
Should your account be delinquent for 30 days, Kids in Sync will automatically bill your credit card for the total payment as well as a $25.00 late fee. You will be responsible for any costs of collecting any past due balances, including collection and litigation costs.*
There will be a $25.00 late fee for any returned check(s)*
In the event that your child is not able to attend the scheduled session, Kids in Sync must be contacted 24 hours prior to the scheduled appointment in order to avoid a no-show fee. The No-Show fee is the full cost of the scheduled appointment, and cannot be billed to insurance.*
We allow for 2 last minute cancellations due to your child’s illness in a 12-month period without charging.*
A $25 LATE PICKUP FEE will be charged for the FIRST late pickup past your child’s session end time. A $50 LATE PICKUP FEE will be charged for the SECOND late pickup, and ANY FURTHER late pickups. We understand that schedules can be busy and unexpected delays can happen, and we appreciate your efforts to plan accordingly. Kids In Sync no longer has a clinic assistant available to wait with children if a caregiver is late for pickup. Because our space provides ample opportunities for movement, the use of our space commands adult supervision. Therefore we cannot confidently leave your child unsupervised, even in our waiting room. For this reason, it is essential that children are picked up on time. Most sessions at Kids In Sync are 50-minute or 80-minute sessions. Please allow extra time to ensure that you or a caregiver will be ready to receive your child at the termination of the session. If a nanny or alternate caregiver is picking up your child, please ensure that they are aware of your child’s scheduled pickup time. If you are unsure what time your child’s session ends, please reach out to your therapist. For questions about this policy, feel free to email Megan at mcarrick@kids-in-sync.com.*
We bill for all services including evaluations, parent feedback meetings, consultations, treatment sessions, group sessions, co-treatment sessions with other disciplines, school visits, etc.*
All phone calls and direct consults will be billed*
Each 15 minutes with a therapist is billed as 1 unit and will be reflected on your bill.*
For cases in which we bill insurance directly, we MUST HAVE A COPY OF THE CURRENT INSURANCE ID CARD.*

We require a valid credit card on file for all accounts with our clinic.

I understand and agree that I am responsible for the entire balance on my account, for all professional services provided to the child (or myself). I have read all the information contained in the financial policy and have completed the above answers. I certify that, to the best of my knowledge, this information is correct and true. I will notify the office in case of any changes to my dependents insurance coverage (or my coverage).

PLEASE CALL DEBBIE SPRINGGATE TO PROVIDE CREDIT CARD INFORMATION AT, 847-337-2029
I understand the above
Signature of Card Holder:
Please agree to and initial under one of the following statements:
1. I understand that the billing office will mail me a statement of services rendered once a month. I authorize them to charge my credit card accordingly. 2. I authorize Kids in Sync Pediatric Occupational Therapy LLC to charge my credit card monthly based on services rendered, and for the amount reflected on my monthly statement.
YesNo
I would prefer to receive all communications from the therapists and staff from Kids in Sync at the following phone number and/or email address:
Signature of parent or caregiver:
Notice of Privacy Practices Acknowledgement

Your signature below indicates that you have read Kids in Sync Privacy Notice and agree to its terms.

Your signature also serves as an acknowledgement that you have received a copy of the privacy notice. We will use and share your health records to treat you and to bill you for the services we provide. We will use and share your health records to run our business. We will use and share your health records as required by law.
I have read and understand the Kids in Sync Privacy Notice and have received satisfactory answers to all questions I have asked regarding its contents. I agree to abide by the terms set forth in theAgreement. I understand that I have the right to revoke my consent to treatment at any time in the future (in writing).*
I have also received a copy of the Kids in Sync Privacy Notice and understand that my therapist will answer any questions I may have about its contents*
I hereby authorize Kids in Sync to release any information, which may be required by my insurance in the process of claims*
Signature
Today's Date

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Date
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School Information

Pregnancy and Birth History

Developmental History

Treatment History

Child Development (Current)

Family History

Provider Information

Understanding of Insurance Allowance