Child Intake Form

Child’s FULL NAME

First NameMiddle NameLast Name

Child’s Date of Birth

Date

Person providing information - Name (Emergency Contact)

Person providing information - Relationship to child

Full address including city, zip code, and state

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Primary Care Physician

What insurance do you have?

Insurance ID Number

Insurance Group Number

Front of INS ID card

Back of INS ID card

Do you have a script for OT? If YES Upload below, If NOT please request and send to our email Pediatrictherapysj@gmail.com OR Fax to 833-466-1909

Script Upload

Primary language at home

What are the main goals for your child?

Has your child been evaluated by other professionals?If yes, please describe prior evaluations

Major surgeries, injuries, or hospitalizations

Does your child have any allergies?

Does your child have an Emergency Action Plan? (seizure, allergy, asthma, diabetes)

Diagnoses

Birth was

Birth complications / Was your child born full term? If yes, please explain

Does your child have a history of seizures?

Describe any accidents, illness, surgeries, etc. since birth

Is your child on any medication? If yes, what?

Does your child use any of the following?

If other equipment, please specify

Age first sat up

Age first crawled

Age first walked

Age first said first words

Age first used two-word phrases

Age toilet trained

School name and address

Grade currently in

Grades repeated

Services presently offered or attending in school

Any school concerns?

Academic areas of concern

Favorite toys or interests

Favorite toys or interests categories

Areas of concern

Dresses self independently

Bathes or washes independently

Brushes teeth independently

Uses the toilet independently

Feeds self independently

Puts on shoes independently

Cleans up after self independently

Manages belongings independently

Follows daily routines independently

Transitions between activities independently

Asks for help when needed

Does your child Toe walk?

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Social Interaction:

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Body awareness:

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Oral Motor

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Sensory processing/Behavior

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Play skills

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Fine motor

Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Visual

Equipment at home

How did you hear about us?

I understand once I fill this form out the clinic will call to schedule my appointment, I am required to have this intake form, a credit card form, and a script in order for services to be rendered. After the initial evaluation the clinic has 2 weeks to write and reach out to your insurance for authorization of services and I understand insurance may prolong starting therapy.

Insurance & Financial ResponsibilityI understand that I am financially responsible for all services provided to my child, including:CopaysDeductiblesCoinsuranceNon-covered servicesServices denied by insuranceI understand that an Explanation of Benefits (EOB) is not a guarantee of payment.If insurance does not cover services for any reason, I agree to pay the private session rate of $90 per 30-minute session.I understand it is my responsibility to notify the office of any insurance changes immediately.All copays and patient responsibility amounts are due at the time of service.A valid credit or debit card must remain on file at all times.By signing this agreement, I authorize Pediatric Therapy of South Jersey to securely store my card information through Stripe via SimplePractice and to charge the card on file for:CopaysDeductiblesCoinsuranceOutstanding balancesLate cancellation or no-show feesCopays will be processed at the conclusion of each therapy session. There will be no phone call prior to charge.If exact cash is placed in the drop box at the time of service, the card will not be charged. If cash is not provided during the visit, the card on file will be processed.If a card declines, I understand I must provide updated payment information before the next scheduled appointment.Accounts with unresolved balances will result in suspension of future appointments until payment is received. Outstanding BalancesIf insurance has paid their portion and there remains a patient balance, Pediatric Therapy of South Jersey may notify me via email or phone.If payment is not received within a reasonable timeframe, I authorize the balance to be charged to my card on file.Accounts with unpaid balances may be placed on hold until resolved.If collection action becomes necessary, I agree to pay reasonable collection costs and attorney fees as permitted by law.

Credit Card AuthorizationI certify that I am an authorized user of the credit/debit card provided.I agree not to dispute charges with my bank or credit card company so long as the charges correspond to the services and policies outlined in this agreement.I understand that credit card transactions may be linked to Protected Health Information.This authorization will remain in effect until the card expires or I submit written notice revoking authorization to pediatrictherapysj@gmail.com.

Cancellation & No-Show PolicyWe understand that occasional changes may be necessary. Schedule changes must be made at least 24 hours in advance.Late cancellations or missed appointments will result in the following fees:First occurrence: $30Second occurrence: $60Third occurrence: $90 and possible discontinuation of therapy servicesIf a session is rescheduled and then canceled again, a $50 no-show fee will apply.If I arrive more than 15 minutes late, I understand the session may be shortened and I am responsible for the full session fee.No-show and late cancellation fees will be charged to the card on file.

Attendance & SchedulingI understand:Evaluations may take up to 2 weeks to complete and send.A physician script stating “Evaluate and Treat” with diagnosis code is required.Insurance authorization may take up to 2 weeks after submission.Visit limits are not a guarantee of authorization.If therapy is recommended 2x/week and I attend only 1x/week, progress may be delayed.Consistent attendance is required to maintain scheduled time slots.Failure to maintain financial standing or attendance expectations may result in discharge from services.

Safety & SupervisionI understand:All Certified Occupational Therapy Assistants are supervised by a Licensed Occupational Therapist.Parents and accompanying individuals must remain in the waiting area unless invited into the therapy space.Children may not be dropped off early or picked up late.The sensory gym door remains locked for safety. (Galloway Location)The door code will not be shared with parents.

All therapy sessions are documented and signed by the treating therapist as well as the supervising therapist.We limit the disclosure of your protected health information (PHI) to that necessary for treatment, payment and operations, as follows:Treatment refers to specific sharing and use of your PHI relating to your direct care. This includes our employees, other consulting professionals and any disease management programs involved in your treatment. Payment refers to specific sharing and use of your PHI for purposes of obtaining payment, including billing and collection from your primary and supplemental insurance carriers.Operations refers to specific sharing and use of your PHI necessary for our administrative operations. These could include—but are not limited to—quality assessment, employee review, student training and other business activities.

While appropriate precautions and safety measures should always be taken, ultimately, the responsibility lies with the parent or guardian to make an informed decision about the potential risks and benefits of this type of therapy for their child. By signing a consent form acknowledging these risks, parents acknowledge that they understand and accept responsibility for any adverse reactions that may occur during treatment.

Services at Pediatric Therapy of South Jersey can have benefits and risks. Informed consent means being aware of both possibilities.Benefits include gaining increased independence, increased motor functioning, increased sensory regulation, and overall greater sense of well-being and health.Since the physical response with sensory input can vary widely from person to person, it is not always possible to accurately predict a person’s response to a certain therapy or procedure.A Client (or parent/guardian) has the right to ask questions about what type of treatment will be received and discuss with the therapists, the potential risks and benefits of each specific recommendation. A Client (or parent/guardian) has the right to decline any portion of treatment at any time during the treatment sessions.I acknowledge that I understand the benefits and risks of Sessions as outlined above and I wish to proceed with my child's assessment and/or treatment Intervention programs usually involve the use of specialized equipment such as various swings, bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh, and lotion), and a variety of other activities that involve fine, gross, and oral motor coordination.Therapy activities often involve encouraging the child to try new things in order to foster increased skills and abilities. While staff make great efforts to ensure each child's safety, the nature of the therapeutic intervention includes the risk of injury in falling and bumping into other people/equipment. I am aware of the inherent risk of this type of activity and I give permission for my child to participate in therapy as described.

In the event medical attention is required for your child while on the premises, we need your authorization to implement treatment. Please read and sign the statement below.As legal guardian, I give my permission for Pediatric Therapy of South Jersey to contact emergency personnel in the event of a medical emergency.

SAFETY AND PHYSICAL CONTACT Pediatric Therapy of South Jersey and all Therapists assure to the best of their ability that your child is kept safe in the office. If a child should engage in behaviors dangerous to her/himself or therapists during a session and cannot stop these behaviors independently, Therapist can cancel the sessions at any time with payment still provided. In addition, in the course of assessment or treatment, young children sometimes seek physical contact with the therapist in the form of hugs. Pediatric Therapy of South Jersey assures that any physical contact is positive and safe due to sensory seeking behaviors. Parents are encouraged to contact the Therapist whenever they have questions about their child’s treatment.

Child Intake Form

Child and Parent/Guardian Information

Insurance

Medical Background /History

Developmental, School, and Daily Living History

Polices and Procedures