Pediatric Patient Intake Form

Pediatric Patient Intake Form

for Speech or Occupational Therapy Services
Please Note:

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

Please do not print these forms. Please fill them out online at least 24 hours before your first visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential.
Page 1 of 13

Cancellation Policy:
Please mark the date of your Appointment on your calendar. While we make every effort to remind our clients of appointments, it is the client's responsibility to maintain his or her schedule. Up to 3 unexcused cancellations are allowed before services are suspended. A twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our therapists and clients on our waitlist. Our therapists will work with you to schedule a make-up session for excused cancellations. Thank you for your cooperation.
Signature*

Clear
Page 2 of 13

Patient Consent Form for Collection, Use, and Disclosure of Personal Information
Privacy of your personal information is an important part of Children's Therapy Group, while providing you with quality speech and occupational therapy. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.

Our Privacy Policy at Children's Therapy Group outlines what we are doing to ensure that:
- Only necessary information is collected about you;
- We only share your information with your consent;
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
How our Clinic Collects, Uses and Discloses Patients’ Personal Information:

The Children's Therapy Group understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information.

The clinic will collect, use and disclose information about you for the following purposes:
- To assess your health concerns
- To provide health care
- To advise you of treatment options
- To establish and maintain contact with you
- To send you newsletters and other information mailings
- To remind you of upcoming appointments
- To communicate with other treating health-care providers
- To allow us to efficiently follow-up for treatment, care and billing
- To complete claims for insurance purposes
- To invoice for goods and services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements
By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.
Patient Consent:
I have reviewed the above information that explains how The Children's Therapy Group will use my personal information and the steps that the clinic is taking to protect my information.

I agree that The Children's Therapy Group can collect, use and disclose personal information as set out above in the information about the clinic privacy policies.
Full Name*

First NameLast Name
Todays Date

MonthDayYear
I have reviewed the above information that explains how CHILDREN'S THERAPY GROUP will use my personal information and the steps that the clinic is taking to protect my information. I agree that the CHILDREN'S THERAPY GROUP can collect, use and disclose personal information about (the signed) as set out above in the information about the clinic privacy policies. Signature*

Clear
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Informed Consent
Please note that this form must be signed prior to your first appointment.
Full Name (of Patient)*

First NameLast Name
Full Name (of Guardian)*

First NameLast Name
Todays Date

MonthDayYear
Signature of Patient or Guardian Indicating that they have read and agree to Informed Consent*

Clear
Page 4 of 13

Email Consent
In order to contact patients about clinic changes, products, events, newsletters, workshops and programs, we require your consent below. You may choose to unsubscribe at any time and you will no longer receive emails from The Children's Therapy Group.

Brook Todd, M.Ed, CCC-SLP, Owner

The Children's Therapy Group

1509 Atkinson Rd, Suite 2200

Lawrenceville, GA

678.858.4777

childrenstg@yahoo.com
I consent to being emailed by The Children's Therapy Group for purposes of staying informed and communicating about changes in the clinic*

Clear
Page 5 of 13

Health History
How would you describe your child's general state of health?*

ExcellentGoodFairPoor
Any Current Diagnoses?
Past Diagnoses and Past Medical History:
Is your child currently under the care of any other physicians, therapists or specialists? Please explain.
Please upload any evaluation reports you have received in the last 6 months from other providers

Browse Files

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Food Allergies, Sensitivities and Intolerances
Environmental Allergies (latex, dust mites, animal dander / fur, hayfever etc)
Which Screening Tests has your child had? (Hearing, Vision, Blood, etc)
Has your child received previous therapy (Speech, OT, PT)?

YesNo
If yes, please explain which types of therapy and for how long.

Therapy Goals
What are your concerns regarding your child’s development?*
What would you like to see your child be able to do as a result of receiving therapy (Speech, OT, PT)?*
Last Question!

Insurance Information
Primary Insurance Company*
Address to send Insurance Claims

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim Phone Number*

Area CodePhone Number
Name of Primary Insurance Carrier*

First NameLast Name
DOB*

MonthDayYear
Date
ID card #*
Group #*
Employer Name*
Please upload a copy of your insurance card

Browse Files
front and back of card Cancelof
Seondary Insurance Company
Address to send Insurance Claims

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim Phone Number

Area CodePhone Number
Name of Secondary Insurance Carrier

First NameLast Name
DOB

MonthDayYear
Date
ID card #
Group #
Employer Name
Please upload a copy of your insurance card

Browse Files
front and back of card Cancelof

Authorizations
Treatment Authorization
Your Name*

First NameLast Name
Your Child's Name*

First NameLast Name
I hereby authorize Children’s Therapy Group, Inc. to evaluate and/or provide speech-language/occupational/physical therapy services for my child.*

Clear
Release of Information
I authorize Children’s Therapy Group, Inc. to release pertinent protected health information (PHI), for the above client, in order to provide treatment, process payments and perform necessary healthcare operations.*

Clear
Billing Authorization
I authorize Children’s Therapy Group, Inc. to bill any participating parties for speech-language pathology/occupational/ physical therapy services received by the client. *

Clear
These parties include the following: (Please check all that apply and fill in information for each below)

Private InsuranceMedicaidBabies Can't WaitPeach StateAmerigroupCare SourceAmbetter
Patient Responsibility

Patient/Parent/Guardian is responsible for payment of any applicable co-pay/co-insurance/deductible or non-covered services at the time of service. Payment must be received prior to your child's therapy session. I accept financial responsibility for all services rendered on my child's behalf. I accept responsibility for all co-payments, deductibles and non-covered services as stated by my insurance coverage.
Signature*

Clear
Should be Empty:

Cancellation Policy:

Patient Consent Form for Collection, Use, and Disclosure of Personal Information

Informed Consent

Email Consent

Demographic Information

Communication

Therapy Goals

Insurance Information

Authorizations

Patient Responsibility