Our onboarding process is designed to be simple and efficient. To get started, please complete the following questionnaire and review and sign all required consent forms.

Please ensure all sections are completed in full, as this information is necessary to accurately and efficiently process your child’s onboarding.

This document must be completed by a parent or legal guardian only. Authorizations and consent forms may only be signed by individuals legally authorized to consent to services.

If you have any questions, please contact us at 954-689-0730 or email intake@therapyredesigned.com.

We look forward to working with you and your family.

— The Language Link Therapy Team

Please list all insurance plans under which your child is currently covered. This includes commercial plans, Medicaid plans, and any supplemental insurance.

If your child has more than one insurance policy, you are required to provide complete information for each plan.

Insurance carriers require providers to bill claims in accordance with coordination of benefits (COB) guidelines. Failure to disclose all active coverage may result in claim denials and financial responsibility for services.

Language Link Therapy offers cash-pay (private pay) options for speech and occupational therapy services. Cash pay may be used if a patient does not have active insurance coverage, if benefits are excluded or exhausted under the patient’s plan, or if the parent/guardian elects not to utilize insurance benefits.

Cash Pay Rates

Evaluation: $150.00
Progress Report: $100.00
30-Minute Therapy Session: $70.00
60-Minute Therapy Session: $100.00

These rates reflect standard services. Any additional or non-standard services will be discussed and agreed upon prior to being provided.

Insurance & Financial Responsibility

I understand and agree to the following:

• If my insurance coverage becomes inactive, terminated, or otherwise unavailable, I agree to be financially responsible for all services rendered at Language Link Therapy’s current cash-pay rates.
• If my insurance plan does not cover certain services, I agree to be financially responsible for those services at the established cash-pay rates.
• I understand that verification of benefits is not a guarantee of payment by my insurance carrier.
• I acknowledge that final determination of coverage is made by my insurance carrier, and I remain financially responsible for any services not covered or paid.
• I authorize Language Link Therapy to charge the applicable cash-pay rates for any services that are not covered or paid by my insurance, as outlined in this agreement.
• Payment for cash-pay services is due at the time services are rendered unless otherwise agreed upon in writing.

Language Link Therapy will make reasonable efforts to notify me if services are expected to be non-covered; however, such notification is not guaranteed.

Additional Terms

• Language Link Therapy will notify me in advance of any services that fall outside standard rates.

Rates are subject to change with prior notice.

Acknowledgment & Consent

By signing below, I acknowledge that I have read, understand, and agree to the Cash Pay Disclosure and Financial Responsibility terms outlined above.

 

Language Link Therapy and its providers are registered with Step Up For Students and may accept scholarship funds toward the cost of services.

Families may choose to use Step Up For Students funds to cover patient financial responsibility, including copayments, deductibles, and coinsurance. In some cases, families may elect to use scholarship funds to cover services in full.

For the purpose of verifying benefits, a diagnosis of Autism Spectrum Disorder (ASD) may impact the coverage available under your child’s health insurance plan.

Note: If your child has been diagnosed with Autism, a formal referral or prescription from your child’s physician, including the Autism diagnosis, will be required prior to initiating services.

If your child is currently undergoing evaluation for a potential diagnosis, services will be provided and billed under your plan’s medical benefits for general speech and/or occupational therapy until a formal diagnosis is established.

Language Link Therapy provides Speech and Occupational Therapy services. In order to begin services, prior authorization may be required based on your child’s insurance plan.

If your child has received speech and/or occupational therapy services within the past six (6) months, you are required to disclose this information.

For insurance plans that require authorization, a formal discharge from a current or recent provider may be required prior to initiating services with Language Link Therapy.

Please note that many insurance plans do not allow multiple providers to render the same therapy service concurrently. As a result, you may be required to discontinue services with another provider before starting services with Language Link Therapy.

 

**NOTE** This disclosure excludes services provided in a public school under an IEP.  You are not requried to discharge from services provided under an IEP.

**If you do not have a current referral (dated within the past 60 days), or if your referral is issued to another provider, please contact your pediatrician to obtain an updated referral**

**If you do not have a current referral (dated within the past 60 days), or if your referral is issued to another provider, please contact your pediatrician to obtain an updated referral**

In order to begin services with Language Link Therapy, a referral or prescription from your child’s pediatrician may be required, depending on your insurance plan.

If your child has not completed their annual well-child visit, the pediatrician may decline to issue a referral for therapy services.

If your child is due for an annual wellness exam, please contact your pediatrician to schedule this appointment as soon as possible to avoid delays in care.

If there is any additional information you would like us to know, please provide details below.

The purpose of this questionnaire is to initiate the onboarding process, verify insurance benefits, and ensure we are able to accommodate your family for the requested services.

Once onboarding is complete, you will be transitioned to the clinical intake process.

1. Consent to Treat

I consent to the provision of therapy services by Language Link Therapy (“LLT”), including services provided by its employees, independent contractors, and other authorized healthcare providers.

I understand that services may include, but are not limited to: Speech Therapy, Occupational Therapy, and Physical Therapy.

I acknowledge that services may be provided in various settings, including but not limited to: clinic, school, home, ABA center, or community-based environments, and that this consent applies to all such locations.

I understand that my child’s care team may include licensed therapists as well as supervised licensed assistants, including Speech-Language Pathology Assistants (SLPAs), Certified Occupational Therapy Assistants (COTAs), and Physical Therapy Assistants (PTAs), in accordance with applicable laws and regulations.

I understand that therapy is not an exact science, and no guarantees have been made regarding outcomes of evaluation or treatment.

 

2. Authorization for Treatment and Referrals

I understand that certain insurance plans may require a referral or prescription from my child’s physician prior to initiating services.

If my child has received therapy services within the past six (6) months, I agree to disclose this information. I understand that a formal discharge from a prior provider may be required before services can begin.

I acknowledge that many insurance plans do not allow multiple providers to deliver the same service concurrently and that I may be required to discontinue services with another provider prior to initiating services with LLT.

3. Financial Responsibility

I understand and agree that LLT will bill my insurance for services, and that I may be responsible for out-of-pocket expenses, including but not limited to copayments, coinsurance, deductibles, or non-covered services.

LLT may collect estimated patient responsibility at the time of service and may require a credit card on file for payment of balances.

I agree to pay any outstanding balance within thirty (30) days of notice. Failure to do so may result in suspension of services until the balance is resolved.

I personally guarantee payment of all charges incurred. Unpaid balances may accrue interest at 1% per month, and LLT may refer accounts to collections, which may result in additional fees.

If I fail to provide accurate or current insurance information, I understand that I am fully responsible for all charges.

Any overpayments may be applied to outstanding balances on any account associated with LLT.

Failure to disclose additional insurance coverage or concurrent services may result in claim denials and full financial responsibility for services rendered.

4. Coordination of Benefits (COB)

I understand that if my child is covered under more than one insurance plan, Coordination of Benefits (COB) rules will apply.

I agree to provide complete and accurate information for all insurance coverage and to notify LLT of any changes.

Failure to disclose additional insurance coverage or comply with COB requirements may result in claim denials, delays, or recoupments, and I accept full financial responsibility for all resulting balances, including payment in full for services rendered.

5. Insurance Acknowledgment

I understand that insurance benefit information is not a guarantee of payment. Insurance carriers may deny claims, provide incorrect information, or process claims inaccurately.

I acknowledge that I am ultimately responsible for all charges not paid by insurance.

6. Cancellation and No-Show Policy

I agree to provide at least 24 hours’ notice for cancellations.

Cancellations made with less than 24 hours’ notice or missed appointments may result in a $25.00 fee per scheduled service, which must be paid prior to future services.

7. Credit Card Authorization

I authorize LLT to charge my credit card for any balances due. I understand my payment information will be stored securely.

If a payment is declined, I agree to provide updated payment information promptly.

 

8. Use and Disclosure of Information (HIPAA)

I authorize LLT to use and disclose my child’s protected health information as necessary for:

• Treatment
• Payment
• Healthcare operations

I acknowledge that I have received or have been provided access to LLT’s Notice of Privacy Practices, which describes my rights regarding protected health information.

9. Communication and Media Consent (Opt-In Required)

Language Link Therapy (“LLT”) offers multiple methods of communication and caregiver engagement. Some of these methods may involve the transmission of protected health information (“PHI”) and may not be fully secure.

Please indicate your preferences below:

LLT to communicate with me via email and/or text messaging, including information related to scheduling, services, and my child’s care.

I understand that these methods are not secure and may involve some risk to the privacy of PHI. I acknowledge and accept these risks and request these methods of communication.

LLT to utilize Google Classroom as a caregiver education and communication tool. While reasonable precautions are taken, this platform is not intended for the transmission of highly sensitive medical information.

I understand that this platform is used at my request and I acknowledge and accept these risks and understand that participation is voluntary.

I understand that any content shared through Google Classroom remains the property of LLT and is provided solely for caregiver education purposes.

I understand and agree that LLT may, at its sole discretion, transition to alternative communication or caregiver engagement platforms in the future. By providing consent for Google Classroom, I acknowledge and agree that this consent shall apply to such alternative platforms, and that additional consent may not be required, provided the purpose and use of such platforms remain substantially similar.

LLT to take and use photographs and video recordings of my child for purposes related to treatment, caregiver education, and healthcare operations.

I understand that:

• Media will not be used for marketing or public distribution without separate written consent
• Media may be shared with me through approved communication platforms

Parent/Guardian Responsibilities

I understand that any information, images, or recordings shared with me are confidential and intended solely for my personal use in supporting my child’s care.

I agree not to share, distribute, or publish any such content without prior written consent from LLT.

Acknowledgment

I understand that all communication methods above are optional, and I may revoke my consent at any time in writing. Revocation will apply prospectively only and will not affect communications already sent or in progress.

10. Legal Caregivers and Authorized Individuals Requirement

I understand that I am required to provide the names and contact information for all legal caregivers/guardians and any individuals who may be involved in my child’s care or may request information from LLT.

For each authorized individual, I must provide:

• Full Name
• Date of Birth
• Relationship to the Patient
• Mobile Phone Number
• Email Address

LLT will not release information to any individual who is not listed and authorized in the patient record except as otherwise permitted or required by law.

Changes in Legal Guardianship or Authorized Individuals

I agree to notify LLT promptly and in writing of any changes to legal guardianship, custody arrangements, or authorized individuals.

I understand that LLT will rely on the most current information provided and will not be responsible for disclosures made in good faith based on previously provided authorization information.

I further understand that LLT may require supporting legal documentation (e.g., custody agreements or court orders) to update or restrict access to information.

LLT will provide equal access to information to legal guardians unless otherwise restricted by valid legal documentation.

 

11. Recording Policy

I understand that audio or video recording of Language Link Therapy (“LLT”) therapists, staff, or my child’s therapy sessions by parents, caregivers, or any third parties is strictly prohibited without prior written consent from LLT.

I acknowledge that all therapy sessions and interactions with LLT staff are considered confidential and may involve protected health information.

I understand that LLT may, with my consent, record therapy sessions or portions thereof for purposes related to treatment, caregiver education, and healthcare operations, including sharing such recordings with me through approved communication platforms (e.g., Google Classroom).

Any recordings created by LLT remain the property of LLT and are provided for caregiver education purposes only.

Unauthorized recording by any party may result in termination of services and/or other appropriate action, in accordance with LLT policies and applicable law.

12. Assignment of Benefits

I authorize LLT to bill my insurance directly and assign all payments for services rendered to LLT.

13. Limitation of Liability, Hold Harmless, and Site of Service Acknowledgment

To the fullest extent permitted by law, I agree to release, indemnify, and hold harmless Language Link Therapy (“LLT”), its employees, contractors, and agents from any claims, liabilities, damages, or expenses arising out of participation in therapy services, except in cases of gross negligence or willful misconduct.

I understand that therapy services involve inherent risks, and I voluntarily assume those risks on behalf of my child.

I further understand that LLT may provide services in locations not owned or operated by LLT, including but not limited to schools, daycare centers, ABA centers, or other community-based settings.

I acknowledge that LLT does not control the operations, staff, policies, or physical environment of these third-party locations and is not responsible for the actions or omissions of such third parties.

I understand that safety, supervision, and environmental conditions at these locations are the responsibility of the hosting facility and/or caregivers, not LLT.

I agree to release and hold harmless LLT from any claims or liabilities arising from conditions or events occurring at these third-party locations, except in cases of gross negligence or willful misconduct by LLT.

14. Incident Reporting and Limitation of Responsibility

I understand that LLT therapists may, in the course of providing services, observe, document, or report incidents involving my child or others at a service location.

I acknowledge that any such documentation or communication is performed solely for purposes of clinical documentation, safety awareness, and coordination of care, and does not imply responsibility or liability on the part of LLT.

I understand that LLT is not responsible for incidents, injuries, or events that occur outside the direct provision of services by LLT, including those involving third-party providers, staff, or environments.

I agree that the act of documenting or reporting an incident shall not be interpreted as an assumption of responsibility, supervision, or control over the individuals or environment involved.

15. Acknowledgment and Signature

I understand that I may revoke this consent in writing; however, such revocation will not apply to actions already taken.

I certify that I am the parent or legal guardian of the patient, or otherwise authorized to sign on the patient’s behalf.

I have read, understand, and agree to the terms outlined in this Consent to Treat and Financial Policy.

Effective Date: 04/08/2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Please review it carefully.

OUR LEGAL DUTY

Language Link Therapy (“LLT”) is required by law to:

• Maintain the privacy and security of your protected health information (“PHI”)
• Provide you with this Notice of our legal duties and privacy practices
• Notify you following a breach of unsecured PHI

This Notice applies to all records of your care created or maintained by LLT.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

We may use and disclose your health information without your written authorization for the following purposes:

1. Treatment

We use your information to provide therapy services and coordinate care. This may include sharing information with:

• Therapists and clinical staff
• Supervisors and trainees
• Other providers involved in your child’s care (e.g., physicians, ABA providers, schools)

2. Payment

We use and disclose your information to obtain payment for services, including:

• Submitting claims to insurance plans
• Verifying benefits and authorizations
• Collecting payment for services rendered

3. Health Care Operations

We may use your information to:

• Improve the quality of services
• Conduct training and supervision
• Perform audits, compliance, and administrative activities
• Manage scheduling and care coordination

We may share information with business associates (such as billing companies and software providers) who are required by contract to safeguard your information.

4. Appointment Reminders and Communication

We may contact you regarding appointments or services via:

• Phone calls or voicemail
• Text messages
• Email
• Digital platforms or portals

You may request alternative communication methods at any time.

5. Individuals Involved in Care

We may share relevant information with parents, legal guardians, or caregivers involved in the child’s care, unless you notify us otherwise in writing.

6. Required by Law

We will disclose your information when required by federal, state, or local law, including:

• Reporting abuse, neglect, or domestic violence
• Responding to court orders or legal proceedings
• Law enforcement requests

7. Public Health and Safety

We may disclose information to:

• Prevent or control disease or injury
• Report adverse events or safety concerns
• Prevent a serious threat to health or safety

8. Health Oversight Activities

We may disclose your information to regulatory agencies for audits, investigations, inspections, and licensure activities.

9. Workers’ Compensation

We may disclose information as required by workers’ compensation laws or similar programs.

10. Business Transfers

If LLT is sold, merged, or reorganized, your health information may be transferred as part of that transaction. All privacy protections will continue to apply.

11. Breach Notification

We will notify you as required by law if your unsecured protected health information is compromised.

USES AND DISCLOSURES REQUIRING AUTHORIZATION

Uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke your authorization at any time in writing.

YOUR RIGHTS

You have the following rights regarding your health information:

1. Right to Request Restrictions

You may request restrictions on how your information is used or disclosed. We are not required to agree to all requests.

2. Right to Request Confidential Communications

You may request that we contact you in a specific way or at a specific location.

3. Right to Access Your Information

You have the right to inspect and obtain a copy of your health information in paper or electronic format.

4. Right to Request Amendments

You may request corrections to your health information if you believe it is incorrect or incomplete.

5. Right to an Accounting of Disclosures

You may request a list of certain disclosures we have made of your information.

6. Right to a Copy of This Notice

You have the right to receive a paper or electronic copy of this Notice at any time.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. Any revised Notice will apply to all health information we maintain and will be made available upon request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with:

Privacy Officer: Ryan Wexler
Language Link Therapy

You may also file a complaint with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

ACKNOWLEDGMENT

I have received and reviewed this Notice of Privacy Practices.

 

I, the undersigned, certify that I am the legal parent or authorized guardian of the minor child identified below and authorize the disclosure of the child’s protected health information (“PHI”) in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Persons Authorized to Disclose Information

I authorize any physician, hospital, clinic, therapist, pharmacy, insurance plan, school, or other health care provider or entity that has provided care or services to my child (each, an “Authorized Provider”) to disclose the child’s PHI as described below.

Persons Authorized to Receive Information

I authorize disclosure of my child’s PHI to:

Language Link Therapy, Inc., including their employees, contractors, and representatives, for purposes of treatment, care coordination, and related health care operations.

Description of Information to Be Disclosed

This authorization applies to medical and educational records related to my child’s care, including but not limited to:

• Evaluations and reports
• Treatment notes
• Medical and developmental history
• Test results
• Billing and insurance records

This may include sensitive information (such as developmental, behavioral, or mental health information) to the extent permitted by applicable law.

Purpose of Disclosure

The purpose of this authorization is to allow Language Link Therapy to:

• Evaluate the child’s needs
• Provide therapy services
• Coordinate care with other providers
• Develop and implement treatment plans

Expiration

This authorization will remain in effect until one (1) year following the last date of treatment provided by Language Link Therapy.

For purposes of this authorization, treatment includes ongoing or intermittent therapy services. If no services are provided for a continuous period of one (1) year, this authorization will expire.

Right to Revoke

I understand that I may revoke this authorization at any time by providing written notice to the disclosing provider.  Revocation will not apply to information already disclosed in reliance on this authorization.

No Conditioning of Treatment

I understand that signing this authorization is voluntary, and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

Potential for Re-Disclosure

I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient; however, Language Link Therapy will continue to protect this information in accordance with applicable privacy laws.

Method of Disclosure

I authorize records to be released via fax, secure email, electronic transmission, or other customary methods of record sharing.

Authority to Sign

I certify that I am the legal parent or authorized guardian of the minor child and have the authority to sign this authorization. I agree to provide documentation of such authority if requested.

Acknowledgment

I have read and understand this authorization and have had the opportunity to ask questions.

 

Please read the following carefully:

Language Link Therapy (“LLT”) requires a completed HIPAA Authorization Form in order to communicate and share information regarding your child’s care with any third party.

This includes, but is not limited to:

• Schools, daycares, and ABA providers
• Caregivers or family members (e.g., grandparents, nannies)
• Any individual or organization involved in your child’s care

When This Form Is Required

This authorization is required in the following situations:

• When services are provided in a school, daycare, or ABA setting
• When coordination of care with another provider is necessary
• When you request or allow a third party to be present during therapy sessions

Important

Without a completed authorization:

• LLT will not be able to communicate with or share information with third parties regarding your child’s care
• LLT may be limited in its ability to provide services in certain settings where coordination or communication is necessary

This requirement is in place to protect your child’s privacy and to ensure appropriate coordination of care.

I, the undersigned, certify that I am the legal parent or authorized guardian of the minor child identified below and authorize Language Link Therapy (“LLT”) to use and disclose the child’s protected health information (“PHI”) as described in this authorization.

Authorized Third Parties

I authorize LLT to communicate and share information with the following individual(s) or organization(s):

**Examples for Relation to Child**

ABA provider, school, daycare, grandparent, nanny

3. Purpose of Authorization

This authorization allows LLT to:

• Coordinate care with other providers or settings
  Communicate regarding the child’s therapy services
• Allow designated individuals to be present during sessions and/or receive updates
  

 4. Information to Be Disclosed

This authorization includes information related to the child’s care, including:

• Evaluations and reports
• Treatment notes and progress updates
• Diagnosis and therapy plans
• Scheduling and attendance information
  

5. Effective Period

This authorization will remain in effect until the earlier of:

• One (1) year after the child’s discharge from Language Link Therapy, or
• Written revocation by the parent/guardian
  

6. Right to Revoke

I understand that I may revoke this authorization at any time by submitting written notice to:

Language Link Therapy
9508 Griffin Road
Cooper City, FL 33328

Revocation will not apply to information already disclosed in reliance on this authorization.

7. No Conditioning of Treatment

I understand that signing this authorization is voluntary; however, I acknowledge that LLT may be unable to communicate with or coordinate care involving third parties without this authorization, which may impact services provided in certain settings.

8. Potential for Re-Disclosure

I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.

9. Authority to Sign

I certify that I am the legal parent or authorized guardian of the minor child and have the authority to sign this authorization.

10. Acknowledgment

I have read and understand this authorization.

I, the undersigned, certify that I am the legal parent or authorized guardian of the minor child receiving services and consent to the use of telehealth (also referred to as teletherapy) for the child’s care.

1. Nature of Telehealth Services

I understand that telehealth involves the use of electronic communication technologies (such as secure video conferencing) to provide therapy services when the provider and patient are in different locations.

2. Privacy and Confidentiality

I understand that the laws that protect the privacy and confidentiality of my child’s medical information also apply to telehealth services.

While Language Link Therapy (“LLT”) uses secure systems, I acknowledge that there are potential risks to privacy associated with electronic communication.

3. Risks of Technology

I understand that telehealth services may be affected by:

• Internet interruptions
• Audio or video issues
• Technical difficulties with devices or software

These issues may result in delays, interruptions, or inability to complete a session. LLT does not guarantee uninterrupted or error-free technology.

4. Parent/Guardian Responsibilities

I understand that I am responsible for:

• Ensuring the child is in a safe and appropriate environment during sessions
• Providing supervision or assistance as needed
• Maintaining privacy at the child’s location (e.g., limiting background noise and interruptions)
• Protecting access to devices, usernames, and passwords
  

5. No Recording Policy

I understand that telehealth sessions may not be recorded (audio or video) by me or any other individual without prior written consent from Language Link Therapy.

6. Appropriateness of Telehealth

I understand that telehealth may not be appropriate for all situations.
The therapist or I may determine that in-person services are more appropriate and may discontinue telehealth services at any time.

7. Emergency Situations

I understand that telehealth services are not intended for emergency situations.
In the event of an emergency, I will call 911 or seek immediate in-person medical assistance.

8. Voluntary Consent

I understand that participation in telehealth services is voluntary and that I may withdraw consent at any time.

9. Acknowledgment

I have read and understand this consent, have had the opportunity to ask questions, and agree to the use of telehealth services for my child.