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.
Occupational Therapy Services 1:1 Direct Services
Speech Therapy Services 1:1 Direct Services
DIRFloortime Intervention
Social Skills Group (6-8 kids per group) (Not covered by any insurance currently)
Social Skills Groups (2 kids per group) (Not covered by any insurance currently)
Physical Therapy Services (Waiting list being formed)
Other
5
Date of Birth (Patient)* This field is required.
MM/DD/YYYY
6
Sex* This field is required.
Male
Female
7
School Information* This field is required.
School / Daycare Name
Current Grade
Address of School / Daycare
8
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.
9
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
10
Allergies / Precautions / Special Diets:* This field is required.Please type "N/A" if Not Applicable.
11
Primary Contact (Parent/Legal Guardian)* This field is required.
First Name
Last Name
12
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
13
E-mail* This field is required.Please only enter email address if Skill Point Therapy may Email you (Including appointment reminders that are automated)
14
Preferred Phone Number* This field is required.
Area Code
Phone Number
15
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
16
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
17
Are there any custody issues at this time? Please explain and provide court documents as required.
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Large
Normal
Small
Ok
Ok
18
Referring Physician
First Name
Last Name
19
Physician's Phone Number
Area Code
Phone Number
20
Primary Care Physician Name(If different)
First Name
Last Name
21
Please provide a copy of Occupational Therapy Referral.Must be within 6 months of when it was written /please choose next to upload PDF instead of image
22
Occupational Therapy Referral as PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
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23
Please provide a copy of Speech Therapy ReferralMust be within 6 months of when it was written/Please choose next to upload PDF instead of image
24
Speech Therapy Referral as PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
25
Primary Insurance Company* This field is required.If you are private paying - Please indicate that here. We are currently in network with many Florida Medicaid Plans and Tricare. If we are out of network with your insurance - we will be happy to submit for you (Payment required at time of services).
26
Primary Policy #
27
Please Provide Picture of Primary Insurance Card Front
28
Please Provide Picture of Insurance Card Back
29
Primary Insurance Address
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
30
(Primary) Insured's Name
First Name
Last Name
31
(Primary)Insured's SS#
32
(Primary) Insured's Date of Birth
Date
Month
Day
Year
33
(Primary) Insured’s Employer Name:
34
(Primary) Insured's Relationship to Patient:
35
Secondary Insurance CompanyIf you are private paying - Please indicate that here. We are currently in network with many Florida Medicaid Plans and Tricare. If we are out of network with your insurance - we will be happy to submit for you (Payment required at time of services).
36
Secondary Policy #
37
Please Provide Picture of Secondary Insurance Card Front
38
Please Provide Picture of Insurance Card Back
39
Secondary Insurance Address
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
40
(Secondary) Insured's Name
First Name
Last Name
41
(Secondary) Insured's Date of Birth
Date
Year
Month
Day
42
(Secondary) Insured's SS#
43
(Secondary) Insured’s Employer Name:
44
(Secondary) Insured's Relationship to Patient:
45
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.
46
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
47
What is your main concern for your child at this time:* This field is required.(Why are you looking for therapy services)
48
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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49
Are there things about your religious beliefs we should know that may impact therapy or activities chosen.
50
Birth History
Complications?
Delivery type?
Late or Early? How many weeks.
Was your child in the NICU?
51
Current diagnosis pertaining to your child:* This field is required.If no diagnosis, type N/A.
52
Does your child have any of the following* This field is required.If Yes, please explain.
Yes
No
Explanation
Frequent Colds / Respiratory Illness
Row 0, Column 0
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?
55
How would you describe your child?
56
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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Does your child have any feeding difficulties or concerns? If yes, please explain
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Ok
58
Hearing Testing
Has your childs hearing ever been tested?
Where and when was this completed?
Results of testing
Does your child wear hearing aids? If so, which ears?
59
Is your child's Speech:* This field is required.
Easy to Understand
Easy for family members to understand but difficult for others to understand
Difficult for both family members and others to understand
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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
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Babbling
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Jargon
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Single Words
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Phrases
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Short Sentences
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Cooing Sounds
Babbling
Jargon
Single Words
Phrases
Short Sentences
Yes
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No
Row 0, Column 1
Unknown
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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
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Unknown
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Age Occurred
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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
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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.
Initial by Checking each box
1. Consent for Evaluation and Treatment I authorize Skill Point Therapy and its licensed providers to evaluate and provide occupational therapy, speech therapy, and/or related services as deemed appropriate for my child. I understand that therapy services may include standardized testing, treatment activities, 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 company directly for services rendered. I understand that: I am financially responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services. All payments and co-pays are due on the day of service. The initial evaluation fee with standardized testing (required by most insurance plans) is $225, and without standardized testing is $175. Standard treatment sessions are $168 per hour. A prompt payment discount may apply if payment is received within 48 hours of invoicing. In the event my insurance denies or delays payment, I agree to be responsible for the remaining balance. Returned checks are subject to a $35 returned check fee, and accounts referred to collections will include applicable collection costs and fees.
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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 essential for therapeutic progress. Cancellations must be made at least 24 hours in advance. A $25 No-Show Fee will apply for missed appointments or cancellations made with less than 24 hours’ notice. This fee is not covered by insurance. After three (3) no-shows, Skill Point Therapy reserves the right to discontinue regular weekly appointments and transition the client to a flexible scheduling status or discharge from care. We understand that emergencies occur; please communicate with our office as soon as possible if unexpected circumstances arise.
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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 compliance with federal and Florida state recordkeeping laws. Copies of evaluations, progress notes, or treatment summaries can be provided upon written request, subject to reasonable copying and administrative fees.
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10. Social Skills Group Payment Policy Skill Point Therapy’s Social Skills Groups are offered in six-week sessions at a total cost of $210.00 per session. To secure a child’s spot, a 50% non-refundable deposit is required at the time of registration. The remaining balance must be paid in full at least 24 hours prior to the session start date. Failure to complete payment by this deadline may result in the child’s spot being forfeited and offered to another participant. Please note that Social Skills Groups are not covered by insurance and may be paid by cash, card, or Step Up funds.
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11. Acknowledgment and Agreement I have read, understand, and agree to the above authorizations, consents, and financial 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 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 therapy, and/or related services as deemed appropriate for my child. I understand that therapy services may include standardized testing, treatment activities, 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 company directly for services rendered. I understand that: I am financially responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services. All payments and co-pays are due on the day of service. The initial evaluation fee with standardized testing (required by most insurance plans) is $225, and without standardized testing is $175. Standard treatment sessions are $168 per hour. A prompt payment discount may apply if payment is received within 48 hours of invoicing. In the event my insurance denies or delays payment, I agree to be responsible for the remaining balance. Returned checks are subject to a $35 returned check fee, and accounts referred to collections will include applicable collection costs and fees.
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 essential for therapeutic progress. Cancellations must be made at least 24 hours in advance. A $25 No-Show Fee will apply for missed appointments or cancellations made with less than 24 hours’ notice. This fee is not covered by insurance. After three (3) no-shows, Skill Point Therapy reserves the right to discontinue regular weekly appointments and transition the client to a flexible scheduling status or discharge from care. We understand that emergencies occur; please communicate with our office as soon as possible if unexpected circumstances arise.
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 compliance with federal and Florida state recordkeeping laws. Copies of evaluations, progress notes, or treatment summaries can be provided upon written request, subject to reasonable copying and administrative fees.
10. Social Skills Group Payment Policy Skill Point Therapy’s Social Skills Groups are offered in six-week sessions at a total cost of $210.00 per session. To secure a child’s spot, a 50% non-refundable deposit is required at the time of registration. The remaining balance must be paid in full at least 24 hours prior to the session start date. Failure to complete payment by this deadline may result in the child’s spot being forfeited and offered to another participant. Please note that Social Skills Groups are not covered by insurance and may be paid by cash, card, or Step Up funds.
11. Acknowledgment and Agreement I have read, understand, and agree to the above authorizations, consents, and financial 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 Florida law.
Initial by Checking each box
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Media Release:* This field is required.Photographs and/or videos may be taken during your child's time at Skill Point Therapy for therapist use to review productions, performance, and progress. I grant permission for my child to be photographed or videotaped.
Display in office / Educational Purposes / Marketing / Promotional Use.
Display in office / Educational Purposes Only
Educational purposes only
I do not grant permission for my child to be photographed or videotaped for display, educational purposes, or marketing.
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Please provide picture of driver's license or photo ID
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Printed name legally responsible person for client:* This field is required.
First Name
Last Name
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Signature of legally responsible person for client:* 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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