SAGE Speech Intake Form

Child's Name*

First NameLast Name
Child's Date of Birth*
Child's Street Address*
Child's Age*
City*
State*
Zip Code*
Primary Parent Full Name*
Primary Parent Email*
example@example.com
Primary Parent Phone*

Area CodePhone Number
Primary Parent DOB*
Parent 2 Email
example@example.com
Parent 2 Full Name

First NameLast Name
Parent 2 Phone Number

Area CodePhone Number
Medical Information
Doctor's Practice Name*
Referring Physician*
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Physician's NPI number
Insurance Information
Medicaid ID
Medicaid Type
Commercial Insurance Company (BCBS ONLY!)
Type of Plan (PPO, HMO, POS, etc)
Primary Insured's Name & DOB (do not leave out DOB)
Member ID
Group #
Policy #
Please describe your current concerns:*
How does your child currently communicate? Please give examples of their speech/language skills, non-verbal communication, etc.*
Does your child have any medical diagnoses (Autism, Hearing Loss, etc):*
Please describe any complications with pregnancy and/or birth:*
Please describe any family history of speech, language, stuttering, reading, and/or learning difficulties:*
Languages spoken at home:*
Age when child began using 2-word phrases:*
Does your child initiate interactions with peers and others:*
Describe how your child plays with toys:*
Did your child have any feeding difficulties as a newborn or infant? please describe.*
What age did your child begin eating solid food?*
Describe any difficulty your child had when solids were introduced:*
Does your child currently refuse any food types (puree, crispy/crunchy, raw vegetables, meats, etc)*
Is your child any of the following: picky eater, messy eater, refuses to chew, spits out food, slow eater, eats too little?*
RefluxDifficulty using strawsMealtime taking more than 30 minutesExcessive droolingGurgly or wet quality voiceHoarse voiceRecurring pneumonia or respiratory infectionsThumb suckingPacifier UseTaking too small bitesChewing for prolonged timeTongue protrusion during eating, drinking or at restCoughing or gagging during mealsFood escaping mouth while eatingTaking too large bitesSpitting out foodFrequent spit up or vomitingDecreased weight gain or growthNone
Has your child participated in previous Physical, Occupational, or Speech therapy? Please describe goals and outcomes.*
Date and results of hearing test:*
Date and results of vision test:*
What is your child's typical weekly schedule, and where do you prefer to have therapy?*
Where Does your child attend school? If there are any learning concerns, please describe*
What are your speech, language, and/or feeding goals for your child?*
Policies & Agreements
Cancellation Policy

FOR CLIENTS USING BLUE CROSS BLUE SHIELD and/or MEDICAID:

Any no-show fee's, late cancellation fee's, and/or travel fees & expenses cannot be submitted to your insurance plan. You are responsible for payment of those fee's in full and subject to our cancellation policies below.

It is the patient/guardian's responsibility to notify SAGE Speech & Learning and/or the child's treating speech pathologist in writing at least TWO WEEKS in advance of any teacher workdays, school conferences, holidays, field trips, special events at home/school, doctors appointments, vacations, etc that may interfere with the child's weekly therapy time.

It is the patient/guardian's responsibility to notify the child's treating speech pathologist in writing at least 48 hours in advance of any cancellation. Failure to notify as stated will result in the full session charge, and is subject to the payment policies outlined in this form. If you must cancel an appointment due to an emergency or sickness, please notify the treating speech pathologist by phone or email/text the evening before your session. If you fail to do so, we reserve the right to charge the full session fee for any appointment that is not kept.
Yes
Consent to Treat

By signing this intake form, I consent for Saren Schapiro, M.Sc., CCC-SLP, and/or other employee's or contracted therapists working for SAGE Speech & Learning Associates, to provide my child with Speech-Language Therapy and other related services, including assessment and intervention for reading, occupational, physical, psychological and tutoring services.
Yes
Yes
Consent to email PHI (Protected Health Information)

By signing this form, I consent for Saren Schapiro, M.Sc, CCC-SLP and/or other employee's or contracted therapists working for SAGE Speech & Learning Associates, LLC, to send any and all protected health information regarding my child via email, which includes but is not limited to; evaluations, treatment notes, weekly session updates, progress notes, etc.
Yes
Yes
Payment Policy: All Clients

Payment in full will be emailed to the primary email provided on this form. Payment in full is due in full within 14 days from your invoice being emailed to you. All patients/guardian's may pay by check, may use the "pay bill" tab on the SAGE Speech & Learning website (www.sagespeech.com) or may pay using the credit card you have elected to keep on file below.

IF NO PAYMENT IS RECEIVED WITHIN 14 DAYS: the credit card on file will be charged in full, plus credit card processing fees. We will NOT refund these payments if your check is late. We will apply a credit to your account if you send a check that is received late. Please refer to fee schedule below for all fee's.

Payments not paid in full within 14 days of the invoice will incur a minimum charge of $10 or 10% of your total bill (whichever is higher). Late fees will continue to accrue an additional 10% of the total invoice each subsequent week the invoice is not paid in full.

All checks should be payable to SAGE Speech & Learning Associates, LLC.

Credit Card transactions will incur a 4% transaction fee which will be added to your invoice amount before submitting payment.
Yes

Fee's

By signing this form, Patient/Guardian agree's to remit payment according to the fee schedule outlined below.

Therapy Process: The typical therapeutic process includes an initial Speech/Language Evaluation, followed by commencing Speech-Language Therapy, if recommended. You will receive a written report with your child's evaluation results and recommendations within 4 weeks and only after payment for evaluation is made.

*Returned checks are subject to a $35 fee.

Effective May 27, 2019, all sessions taking place outside of the SAGE Speech & Learning clinic will incur a $10 per session travel fee. This fee will NOT be covered by BCBS or Medicaid. These fee's will be billed directly to the client/parent/guardian and will be subject to our payment and collections policies, as outlined in this form. Current clients are required to notify SAGE Speech & Learning in writing by May 6, 2019 if they would like to move their therapy sessions to our clinic. If client does not request a clinic session in writing, their sessions will remain at the agreed upon location and incur travel fee's.

All evaluation fee's include a written report.

Travel Fee/Expense (per session) for any sessions occuring outside of the SAGE Speech & Learning clinic (effective May 27, 2019 for all client, including those with insurance and medicaid)	$10
Speech & Language Therapy (sessions are 50 minutes with 5-10 minutes for parent/teacher communication and note writing)	$145- 60 minute session
Speech & Language Therapy (sessions are 40 minutes with 5 minutes for parent/teacher communication and note writing)	$110-45 minute session
Speech & Language Therapy (sessions are 25 minutes with 5 minutes for parent/teacher communication and note writing)	$75- 30 minute session
Oral Motor/Articulation Evaluation	$350
Evaluation of Feeding Skills	$450
Language & Processing Only Evaluation	$450
Comprehensive Articulation & Language Evaluation	$550
Articulation & Language Evaluation for children under 3 years	$400
Professional Letter (to doctors, school, insurance companies, etc)	$25 per letter
Parent-Clinician Meeting/Phone call or In-Person Conference	$145 per hour
Conference with other Medical or Therapeutic service providers, or IEP meeting	$145 per hour

Yes
Cancellation of Services

By signing this form, Patient/Guardian agree's to provide 2 weeks notice, in writing, to the SAGE Speech & Learning office (saren@sagespeech.com) and/or to your treating speech pathologist, if you plan to dismiss the patient from services with SAGE Speech & Learning. A 2 week notification is REQUIRED unless otherwise agreed upon. If you choose to discontinue treatment you are still responsible for paying all services that were provided prior to your decision to discontinue.
Yes
Collection Notice

By signing this form, Patient/Guardian agrees that unresolved financial disputes for non-payment of fees for service rendered could result in the discontinuation of services, referral to another provider as necessary, and assignment of collection responsibility for this account to a professional Collection Agency.

Furthermore, you agree that if it should become necessary for SAGE Speech & Learning to forward your account to a collection agency you will be responsible for the fee charged by the collection agency for the costs of collection.
Yes
Release of Protected Health Information (PHI)

Patient/Guardian authorizes SAGE Speech & Learning to receive or release any medical information to your insurance company, physicians, therapists, or any other parties that may be involved in the child’s care.
YES
Payment Information

The Patient/Guardian understands that the credit card information filled out below will be held on file. Payment can be made according to the payment policies listed above in this form. If payment is not received within 14 days of your invoice being emailed to you, the credit card you elect to place on file will be charged. All credit card transactions have a 4% credit card fee. Should your card be declined, services will be placed on pause until your account is settled.
YES
Full Name on Credit Card*
Zip code for Card*
By signing below, Patient/Guardian is stating they have read and agree to all policies and procedures outlined in the SAGE Speech & Learning intake form packet, and agree to these policies and procedures effective immediately.
Signature of Parent/Guardian
Google searchReferred by a friendFacebookInstagramMy Pediatrician's OfficeMy Child's SchoolOther
Date of Signature*
Please provide a synopsis of your child's typical schedule and where you prefer therapy to be done:*
Where does your child attend school?*
Should be Empty:

Medical Information

Insurance Information

Policies & Agreements