Skill Point Therapy Intake Form 2025

1
Patient Name:* This field is required.
First Name
Middle Name
Last Name
2
Nickname Preferred
3
Which location are you requesting?* This field is required.
Carrollwood Office (13907 N. Dale Mabry Hwy. Suite 214, Tampa, FL 33618)
Brandon Office (1463 Oakfield Drive #131, Brandon, FL 33511)
My Child's School / Daycare / Home
Telehealth Services Only
First Available
4
Which services are you interested in for your child?* This field is required.Please note: Skill Point Therapy practitioners incorporate the DIRFloortime® model into therapy services when clinically appropriate. DIRFloortime® Parent Coaching & Training refers specifically to our separate parent/caregiver training service.
Occupational Therapy
Speech-Language Therapy
Physical Therapy
DIRFloortime Parent Coaching & Training
Social Skills Group - Standard Group
Social Skills Group - 2:1 Group
Therapeutic Enrichment
5
Has your child received Speech, Occupational, or Physical Therapy within the past year? If yes, please list where services were provided and the date your child was last seen. * This field is required.Please note: Insurance does not allow duplicate therapy services. If your child is currently receiving OT, Speech, or PT elsewhere, we will need a discharge note before starting same service at Skill Point Therapy.
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Date of Birth (Patient)* This field is required.
MM/DD/YYYY
7
Sex* This field is required.
Male
Female
8
School Information* This field is required.
School / Daycare Name
Current Grade
Address of School / Daycare
9
Does your child have any accommodations , IEP, or special education services at school? * This field is required.If your child has a current IEP, please email a copy to our office or bring it in for our records. Some insurance companies require that we keep a copy on file.
10
Who is authorized to pick up child (If someone not on this list attempts to remove your child you will be notified immediately)
First and Last Name
Relationship
First and Last Name
Relationship
First and Last Name
Relationship
First and Last Name
Relationship
11
Allergies / Precautions / Special Diets:* This field is required.Please type "N/A" if Not Applicable.
12
Primary Contact (Parent/Legal Guardian)* This field is required.
First Name
Last Name
13
Primary Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
E-mail* This field is required.Please only enter email address if Skill Point Therapy may Email you (Including appointment reminders that are automated)
15
Preferred Phone Number* This field is required.
Area Code
Phone Number
16
Cell Number for Text MessagesPlease only enter number if Skill Point Therapy may text you (including appointment reminders that are automated).
Area Code
Phone Number
17
Emergency Contact* This field is required.Please note this is different than authorized pick up. Emergency contact will be contacted by Skill Point Therapy in the advent we are unable to reach primary contact.
First Name
Last Name
Phone Number (Please include area code)
Relationship to Child
18
Are there any custody issues at this time? Please explain and provide court documents as required.
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19
Referring Physician
First Name
Last Name
20
Physician's Phone Number
Area Code
Phone Number
21
Primary Care Physician Name(If different)
First Name
Last Name
22
Please upload your child's Occupational Therapy referral/order.The referral/order must: State “Occupational Therapy Evaluation and Treatment” Include a diagnosis and diagnosis code Be signed by the ordering provider Be current and valid for the services being requested Upload a clear photo below. If your referral/order is a PDF, select Next to upload the PDF instead.
23
Occupational Therapy Referral as PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
24
Please upload your child’s Speech-Language Therapy referral/order.The referral/order must: State “Speech-Language Therapy Evaluation and Treatment” Include a diagnosis and diagnosis code Be signed by the ordering provider Be current and valid for the services being requested Upload a clear photo below. If your referral/order is a PDF, select Next to upload the PDF instead.
25
Speech-Language Therapy Referral as PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Please upload your child’s Physical Therapy referral/order.The referral/order must: State “Physical Therapy Evaluation and Treatment” Include a diagnosis and diagnosis code Be signed by the ordering provider Be current and valid for the services being requested Upload a clear photo below. If your referral/order is a PDF, select Next to upload the PDF instead.
27
Physical Therapy Referral as PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Will you be using health insurance for Occupational Therapy, Speech-Language Therapy, and/or Physical Therapy services?Please note: Out-of-network benefits and reimbursement are determined by your insurance plan and are not guaranteed. Private-pay payment is due according to Skill Point Therapy's payment policies.
In-Network Insurance – Please bill my insurance.
Out-of-Network Insurance – Office Submission – I would like Skill Point Therapy to submit claims to my insurance when available.
Out-of-Network Insurance – Self-Submit – I will pay Skill Point Therapy’s private-pay rate and submit claims to my insurance myself for possible reimbursement.
Private Pay – No Insurance Submission – I will pay the applicable private-pay rate and do not want claims submitted to insurance.
Non-Insurance Service Only – I am requesting a service that is not billed to health insurance (such as Therapeutic Enrichment, Social Skills Group, or DIRFloortime® Parent Coaching & Training).
29
Primary Health Insurance Company* This field is required.Please enter your child’s primary health insurance company below.
30
Primary Policy / Member ID#
31
Insurance Card - Front
32
Insurance Card - Back
33
Primary Insured's Name
First Name
Last Name
34
Primary Insured's Date of Birth
Date
Month
Day
Year
35
Primary Insured's Relationship to Patient:
36
Does your child have secondary health insurance?* This field is required.
YESNO
37
Secondary Health Insurance Company
38
Secondary Policy / Member ID#
39
Secondary Insurance Card - Front
40
Secondary Insurance Card - Back
41
Secondary Insured's Name
First Name
Last Name
42
Secondary Insured's Date of Birth
Date
Year
Month
Day
43
Secondary Insured's Relationship to Patient
44
Is your child currently receiving requested therapy service at another practice? If so, please indicate which service as well as location they are attending currently.* This field is required.In order to begin Occupational Therapy or Speech Therapy services, if your child is currently receiving or has recently received therapy at another facility, we will need a copy of their most recent evaluation and discharge summary. Please have the previous facility fax this information to us at 877-540-1201.
45
Has your child received any of the following services in the past?
Occupational Therapy
Speech Therapy
Physical Therapy
ABA Therapy
Social Skills Groups
Mental Health Counceling
46
What is your main concern for your child at this time:* This field is required.(Why are you looking for therapy services)
47
What medications is your child taking:* This field is required.Please list all prescribed and over the counter medications (Please type "None" if not taking any at this time).
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48
Are there things about your religious beliefs we should know that may impact therapy or activities chosen.
49
Birth History
Complications?
Delivery type?
Late or Early? How many weeks.
Was your child in the NICU?
50
Current diagnosis pertaining to your child:* This field is required.If no diagnosis, type N/A.
51
Does your child have any of the following* This field is required.If Yes, please explain.
Yes
No
Explanation
Frequent Colds / Respiratory Illness
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Row 0, Column 1
Row 0, Column 2
Frequent Strep Throat / Sore Throat
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Frequent Ear Infections/ Ear Tubes
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Birth Defect / Genetic
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Allergies / Asthma
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Heart Condition
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Seizures or Convulsions
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Hearing Loss / Ear Disorder
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Head Injuries / Concussions
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Any Major Childhood Illnesses
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Hospitalizations / Surgeries
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Neurological Disorders
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Frequent Colds / Respiratory Illness
Frequent Strep Throat / Sore Throat
Frequent Ear Infections/ Ear Tubes
Birth Defect / Genetic
Allergies / Asthma
Heart Condition
Seizures or Convulsions
Hearing Loss / Ear Disorder
Head Injuries / Concussions
Any Major Childhood Illnesses
Hospitalizations / Surgeries
Neurological Disorders
Yes
Row 0, Column 0
No
Row 0, Column 1
Explanation
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Explanation
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Explanation
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Explanation
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Explanation
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Explanation
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Explanation
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Explanation
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Explanation
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
Explanation
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
Explanation
Row 10, Column 2
Yes
Row 11, Column 0
No
Row 11, Column 1
Explanation
Row 11, Column 2
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Family History* This field is required.If there is a member in your family that has had a history of the following, please list the relationship to the patient.
Yes
No
Unknown
Explain
Hearing Loss
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Alcoholism
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Mental Illness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Drug Abuse
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Learning Disability
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Reading Disability
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Speech Disability
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Hearing Loss
Alcoholism
Mental Illness
Drug Abuse
Learning Disability
Reading Disability
Speech Disability
Yes
Row 0, Column 0
No
Row 0, Column 1
Unknown
Row 0, Column 2
Explain
Row 0, Column 3
Yes
Row 1, Column 0
No
Row 1, Column 1
Unknown
Row 1, Column 2
Explain
Row 1, Column 3
Yes
Row 2, Column 0
No
Row 2, Column 1
Unknown
Row 2, Column 2
Explain
Row 2, Column 3
Yes
Row 3, Column 0
No
Row 3, Column 1
Unknown
Row 3, Column 2
Explain
Row 3, Column 3
Yes
Row 4, Column 0
No
Row 4, Column 1
Unknown
Row 4, Column 2
Explain
Row 4, Column 3
Yes
Row 5, Column 0
No
Row 5, Column 1
Unknown
Row 5, Column 2
Explain
Row 5, Column 3
Yes
Row 6, Column 0
No
Row 6, Column 1
Unknown
Row 6, Column 2
Explain
Row 6, Column 3
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What difficulties is your child having socially?
54
How would you describe your child?
55
How often is English spoken at home?
Always
Most of the time
Sometimes
Never
56
Is a language besides English spoken at home, if so which language/s are used in the home?
57
Developmental History* This field is required.Please note if your child is able to do the action below and when they started doing this for the first time. If you do not remember, please put "Unknown"
Unable
Has Completed
Unknown
Age Occurred
Said first word
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Used simple questions
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Followed 1 step directions
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Said 2-3 word phrases
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Lifted head while on stomach
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Rolled over
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Sat unsupported
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Crawled
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Stood unsupported
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Walked unsupported
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Finger Feeding
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Using Spoon to Feed self
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Said first word
Used simple questions
Followed 1 step directions
Said 2-3 word phrases
Lifted head while on stomach
Rolled over
Sat unsupported
Crawled
Stood unsupported
Walked unsupported
Finger Feeding
Using Spoon to Feed self
Unable
Row 0, Column 0
Has Completed
Row 0, Column 1
Unknown
Row 0, Column 2
Age Occurred
Row 0, Column 3
Unable
Row 1, Column 0
Has Completed
Row 1, Column 1
Unknown
Row 1, Column 2
Age Occurred
Row 1, Column 3
Unable
Row 2, Column 0
Has Completed
Row 2, Column 1
Unknown
Row 2, Column 2
Age Occurred
Row 2, Column 3
Unable
Row 3, Column 0
Has Completed
Row 3, Column 1
Unknown
Row 3, Column 2
Age Occurred
Row 3, Column 3
Unable
Row 4, Column 0
Has Completed
Row 4, Column 1
Unknown
Row 4, Column 2
Age Occurred
Row 4, Column 3
Unable
Row 5, Column 0
Has Completed
Row 5, Column 1
Unknown
Row 5, Column 2
Age Occurred
Row 5, Column 3
Unable
Row 6, Column 0
Has Completed
Row 6, Column 1
Unknown
Row 6, Column 2
Age Occurred
Row 6, Column 3
Unable
Row 7, Column 0
Has Completed
Row 7, Column 1
Unknown
Row 7, Column 2
Age Occurred
Row 7, Column 3
Unable
Row 8, Column 0
Has Completed
Row 8, Column 1
Unknown
Row 8, Column 2
Age Occurred
Row 8, Column 3
Unable
Row 9, Column 0
Has Completed
Row 9, Column 1
Unknown
Row 9, Column 2
Age Occurred
Row 9, Column 3
Unable
Row 10, Column 0
Has Completed
Row 10, Column 1
Unknown
Row 10, Column 2
Age Occurred
Row 10, Column 3
Unable
Row 11, Column 0
Has Completed
Row 11, Column 1
Unknown
Row 11, Column 2
Age Occurred
Row 11, Column 3
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If you are requesting Speech-Language therapy - What is the main goal you want to accomplish with speech/language therapy?
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Ok
Ok
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How does your child communicate the following
Gestures
Vocalizations
Crying/Tantrum
Signs/Pictures/AAC
Single words
Spoken Phrases
Unable
Requests an object or activity
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Requests permission to do something
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Denails/Protests
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Greets Others
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Tells you how they feel
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Attempts to get your attention
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Makes comments
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Asks Questions
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Answers Questions
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Requests an object or activity
Requests permission to do something
Denails/Protests
Greets Others
Tells you how they feel
Attempts to get your attention
Makes comments
Asks Questions
Answers Questions
Gestures
Row 0, Column 0
Vocalizations
Row 0, Column 1
Crying/Tantrum
Row 0, Column 2
Signs/Pictures/AAC
Row 0, Column 3
Single words
Row 0, Column 4
Spoken Phrases
Row 0, Column 5
Unable
Row 0, Column 6
Gestures
Row 1, Column 0
Vocalizations
Row 1, Column 1
Crying/Tantrum
Row 1, Column 2
Signs/Pictures/AAC
Row 1, Column 3
Single words
Row 1, Column 4
Spoken Phrases
Row 1, Column 5
Unable
Row 1, Column 6
Gestures
Row 2, Column 0
Vocalizations
Row 2, Column 1
Crying/Tantrum
Row 2, Column 2
Signs/Pictures/AAC
Row 2, Column 3
Single words
Row 2, Column 4
Spoken Phrases
Row 2, Column 5
Unable
Row 2, Column 6
Gestures
Row 3, Column 0
Vocalizations
Row 3, Column 1
Crying/Tantrum
Row 3, Column 2
Signs/Pictures/AAC
Row 3, Column 3
Single words
Row 3, Column 4
Spoken Phrases
Row 3, Column 5
Unable
Row 3, Column 6
Gestures
Row 4, Column 0
Vocalizations
Row 4, Column 1
Crying/Tantrum
Row 4, Column 2
Signs/Pictures/AAC
Row 4, Column 3
Single words
Row 4, Column 4
Spoken Phrases
Row 4, Column 5
Unable
Row 4, Column 6
Gestures
Row 5, Column 0
Vocalizations
Row 5, Column 1
Crying/Tantrum
Row 5, Column 2
Signs/Pictures/AAC
Row 5, Column 3
Single words
Row 5, Column 4
Spoken Phrases
Row 5, Column 5
Unable
Row 5, Column 6
Gestures
Row 6, Column 0
Vocalizations
Row 6, Column 1
Crying/Tantrum
Row 6, Column 2
Signs/Pictures/AAC
Row 6, Column 3
Single words
Row 6, Column 4
Spoken Phrases
Row 6, Column 5
Unable
Row 6, Column 6
Gestures
Row 7, Column 0
Vocalizations
Row 7, Column 1
Crying/Tantrum
Row 7, Column 2
Signs/Pictures/AAC
Row 7, Column 3
Single words
Row 7, Column 4
Spoken Phrases
Row 7, Column 5
Unable
Row 7, Column 6
Gestures
Row 8, Column 0
Vocalizations
Row 8, Column 1
Crying/Tantrum
Row 8, Column 2
Signs/Pictures/AAC
Row 8, Column 3
Single words
Row 8, Column 4
Spoken Phrases
Row 8, Column 5
Unable
Row 8, Column 6
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Does your child have any feeding difficulties or concerns? If yes, please explain
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Normal
Small
Ok
Ok
61
What was the results of your child's most recent vision test?
No testing has been completed
Needs glasses / contacts
Normal / No concerns
Other impairment
62
Has your child had their hearing tested?
YESNO
63
Hearing Testing
What were the results of their hearing test (Normal/Reduced Hearing/Deaf/Auditory Prpocessing Disorder)
Where and when was this completed?
Results of testing
If reduced hearing/deaf results, has your child's hearing been corrected since - If so how (eg: No aids, hearing aids, cochlear implants, tubes)
64
How much of what your child says can you understand?* This field is required.
Almost all
Most
Half
Less than half
None
65
Speech DevelopmentPlease note if your child is able to do the action below and when they started doing this for the first time. If you do not remember, please put Unknown.
Yes
No
Unknown
Age Occurred
Cooing Sounds
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Babbling
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Jargon
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Single Words
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Phrases
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Short Sentences
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Cooing Sounds
Babbling
Jargon
Single Words
Phrases
Short Sentences
Yes
Row 0, Column 0
No
Row 0, Column 1
Unknown
Row 0, Column 2
Age Occurred
Row 0, Column 3
Yes
Row 1, Column 0
No
Row 1, Column 1
Unknown
Row 1, Column 2
Age Occurred
Row 1, Column 3
Yes
Row 2, Column 0
No
Row 2, Column 1
Unknown
Row 2, Column 2
Age Occurred
Row 2, Column 3
Yes
Row 3, Column 0
No
Row 3, Column 1
Unknown
Row 3, Column 2
Age Occurred
Row 3, Column 3
Yes
Row 4, Column 0
No
Row 4, Column 1
Unknown
Row 4, Column 2
Age Occurred
Row 4, Column 3
Yes
Row 5, Column 0
No
Row 5, Column 1
Unknown
Row 5, Column 2
Age Occurred
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Does your child have any accessibility concerns (wheelchair, walker, etc.)* This field is required.
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Please indicate that you have read and understand the following information.* This field is required.
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Please read and check each statement prior to continuing* This field is required.Checking each statement below to indicate understanding.
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1. Consent for Evaluation and Treatment I authorize Skill Point Therapy and its licensed providers to evaluate and provide Occupational Therapy, Speech-Language Therapy, Physical Therapy, and/or other services requested by me and deemed appropriate for my child. I understand that services may include standardized testing, treatment activities, caregiver education, and consultations designed to support my child's individual needs.
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2. Authorization to Release and Obtain Information I authorize Skill Point Therapy to release, obtain and exchange relevant medical, educational, and therapeutic information with physicians, insurance carriers, schools, or other professionals involved in my child’s care for the purpose of evaluation, treatment, billing, and coordination of services. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this consent.
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3. Financial Responsibility and Insurance Authorization I authorize Skill Point Therapy to bill my insurance for covered services when applicable. I understand that I am responsible for any copayments, deductibles, coinsurance, or other amounts that may legally be billed to me. Current prompt-pay private-pay rates are: OT: Evaluation $225; Treatment $100/60 min or $50/30 min. Speech-Language Therapy: Evaluation $250; Treatment $130/60 min or $65/30 min. Physical Therapy: Evaluation $250; Treatment $130/60 min or $65/30 min. I understand that some services may not be covered by insurance. If I voluntarily choose a non-covered private-pay service, I will be informed of the cost in advance and will be responsible for the agreed-upon charges. Rates may be updated with notice.
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4. Legal Guardian Verification I declare that I am the legal parent or guardian of the minor named on this form and have the authority to consent to evaluation and treatment. I understand that I must notify Skill Point Therapy in writing of any changes to my contact information, address, custody status, or insurance coverage during the course of treatment.
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5. Attendance, No-Show, and Cancellation Policy I understand that consistent attendance is important for therapeutic progress. Cancellations must be made at least 24 hours in advance, and a $50 no-show/late cancellation fee may apply to missed appointments or cancellations with less than 24 hours' notice and is not billed to insurance. Three (3) missed appointments in an authorization period or frequent/chronic cancellations may result in the release of my child's regular weekly appointment time and transition to flex scheduling. Families should contact the office as soon as possible when illness, emergencies, or unexpected circumstances occur.
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6. Privacy and Use of Personal Health Information I acknowledge that my child’s Protected Health Information (PHI) may be used or disclosed for purposes of treatment, payment, or healthcare operations, as outlined in Skill Point Therapy’s Notice of Privacy Practices. I understand that I have the right to restrict certain uses and disclosures by submitting a written request. Skill Point Therapy will comply with all applicable HIPAA and Florida privacy laws regarding the safeguarding of health information.
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7. Electronic Communication Consent I understand that communication via email or text message may not be encrypted or fully secure under HIPAA standards. By choosing to communicate through these methods, I consent to this form of correspondence and release Skill Point Therapy from responsibility for unauthorized access that may occur during electronic transmission.
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8. Security and Video Surveillance Skill Point Therapy utilizes video security cameras in common areas, waiting rooms, treatment rooms and hallways for the safety of patients, families, and staff. No cameras are placed in restrooms. By signing this form, I acknowledge and consent to the use of video surveillance within the facility for security and safety purposes.
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9. Access to Records and Documentation I understand that Skill Point Therapy maintains clinical and billing records in accordance with applicable federal and Florida recordkeeping requirements. Copies of evaluations, progress notes, treatment summaries, and other records may be requested in writing and will be provided in accordance with applicable law.
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10. DIRFloortime®-Based Social Skills Group Payment Policy Skill Point Therapy's Social Skills Groups are offered in six-week sessions. Standard Groups are $270 per session ($45/class), and 2:1 Groups are $360 per session ($60/class). A 50% non-refundable deposit is required to reserve a child's spot, with the remaining balance due prior to the start of the session. Social Skills Groups are private-pay services and are not billed to insurance. Payment may be made by cash, card, or eligible Step Up funds.
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11. Acknowledgment and Agreement I have read, understand, and agree to the above authorizations, consents, financial policies, and applicable program policies. I have received or been offered a copy of Skill Point Therapy's Notice of Privacy Practices and understand my rights under HIPAA and applicable Florida law.
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1. Consent for Evaluation and Treatment I authorize Skill Point Therapy and its licensed providers to evaluate and provide Occupational Therapy, Speech-Language Therapy, Physical Therapy, and/or other services requested by me and deemed appropriate for my child. I understand that services may include standardized testing, treatment activities, caregiver education, and consultations designed to support my child's individual needs.
2. Authorization to Release and Obtain Information I authorize Skill Point Therapy to release, obtain and exchange relevant medical, educational, and therapeutic information with physicians, insurance carriers, schools, or other professionals involved in my child’s care for the purpose of evaluation, treatment, billing, and coordination of services. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this consent.
3. Financial Responsibility and Insurance Authorization I authorize Skill Point Therapy to bill my insurance for covered services when applicable. I understand that I am responsible for any copayments, deductibles, coinsurance, or other amounts that may legally be billed to me. Current prompt-pay private-pay rates are: OT: Evaluation $225; Treatment $100/60 min or $50/30 min. Speech-Language Therapy: Evaluation $250; Treatment $130/60 min or $65/30 min. Physical Therapy: Evaluation $250; Treatment $130/60 min or $65/30 min. I understand that some services may not be covered by insurance. If I voluntarily choose a non-covered private-pay service, I will be informed of the cost in advance and will be responsible for the agreed-upon charges. Rates may be updated with notice.
4. Legal Guardian Verification I declare that I am the legal parent or guardian of the minor named on this form and have the authority to consent to evaluation and treatment. I understand that I must notify Skill Point Therapy in writing of any changes to my contact information, address, custody status, or insurance coverage during the course of treatment.
5. Attendance, No-Show, and Cancellation Policy I understand that consistent attendance is important for therapeutic progress. Cancellations must be made at least 24 hours in advance, and a $50 no-show/late cancellation fee may apply to missed appointments or cancellations with less than 24 hours' notice and is not billed to insurance. Three (3) missed appointments in an authorization period or frequent/chronic cancellations may result in the release of my child's regular weekly appointment time and transition to flex scheduling. Families should contact the office as soon as possible when illness, emergencies, or unexpected circumstances occur.
6. Privacy and Use of Personal Health Information I acknowledge that my child’s Protected Health Information (PHI) may be used or disclosed for purposes of treatment, payment, or healthcare operations, as outlined in Skill Point Therapy’s Notice of Privacy Practices. I understand that I have the right to restrict certain uses and disclosures by submitting a written request. Skill Point Therapy will comply with all applicable HIPAA and Florida privacy laws regarding the safeguarding of health information.
7. Electronic Communication Consent I understand that communication via email or text message may not be encrypted or fully secure under HIPAA standards. By choosing to communicate through these methods, I consent to this form of correspondence and release Skill Point Therapy from responsibility for unauthorized access that may occur during electronic transmission.
8. Security and Video Surveillance Skill Point Therapy utilizes video security cameras in common areas, waiting rooms, treatment rooms and hallways for the safety of patients, families, and staff. No cameras are placed in restrooms. By signing this form, I acknowledge and consent to the use of video surveillance within the facility for security and safety purposes.
9. Access to Records and Documentation I understand that Skill Point Therapy maintains clinical and billing records in accordance with applicable federal and Florida recordkeeping requirements. Copies of evaluations, progress notes, treatment summaries, and other records may be requested in writing and will be provided in accordance with applicable law.
10. DIRFloortime®-Based Social Skills Group Payment Policy Skill Point Therapy's Social Skills Groups are offered in six-week sessions. Standard Groups are $270 per session ($45/class), and 2:1 Groups are $360 per session ($60/class). A 50% non-refundable deposit is required to reserve a child's spot, with the remaining balance due prior to the start of the session. Social Skills Groups are private-pay services and are not billed to insurance. Payment may be made by cash, card, or eligible Step Up funds.
11. Acknowledgment and Agreement I have read, understand, and agree to the above authorizations, consents, financial policies, and applicable program policies. I have received or been offered a copy of Skill Point Therapy's Notice of Privacy Practices and understand my rights under HIPAA and applicable Florida law.
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Media ReleasePlease select one option below to indicate your preferences regarding the use of photographs and/or videos of your child.
I give permission for photographs/videos of my child to be used for educational, marketing, promotional, social media, and in-office purposes.
I give permission for photographs/videos of my child to be used for educational and in-office purposes only. No social media, marketing, or promotional use.
I do not give permission for photographs/videos of my child to be used for educational, marketing, promotional, social media, or display purposes.
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Please upload a photo of the responsible party's driver's license or government-issued photo ID.
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Therapeutic Enrichment- Preferred Practitioner* This field is required.Therapeutic Enrichment is an individualized private-pay service designed to provide additional opportunities to practice, strengthen, and expand skills based on your child’s needs and your family’s goals. This service is separate from insurance-billed therapy and is not billed to insurance or Medicaid. Rates: OT Practitioner – $50/30 minutes or $100/60 minutes. Speech-Language Practitioner – $65/30 minutes or $130/60 minutes.
Occupational Therapy Practitioner
Speech-Language Practitioner
No Preference / Please Help Me Determine the Best Fit
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Therapeutic Enrichment – Preferred Session Length* This field is required.Please select your preferred session length and frequency. Requested schedules are subject to practitioner availability.
30 Minutes /1 time weekly
60 Minutes / 1 time weeky
30 Minutes / 2 times weekly
60 Minutes / 2 times weekly
Other
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Therapeutic Enrichment – Private-Pay Acknowledgment* This field is required.I understand that Therapeutic Enrichment is a voluntarily selected private-pay service that is separate from insurance-billed Occupational Therapy, Speech-Language Therapy, and Physical Therapy. Therapeutic Enrichment will not be billed to Medicaid or other health insurance, and participation is not required for my child to receive insurance-covered therapy services at Skill Point Therapy. I understand that I am financially responsible for the applicable Therapeutic Enrichment rate based on the practitioner and session length selected above.
I understand and agree.
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Printed Name of Parent/Legal Guardian or Responsible Party* This field is required.
First Name
Last Name
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Signature of Parent/Legal Guardian or Responsible Party* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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How did you hear about us?* This field is required.
Doctors office
Facebook/Instagram
Website
Friend or Family
School
Google
Other
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