Let's talk business

Feeding Intake Form
Today's date*

MonthDayYear
Date
Child's name*

First NameLast Name
Child's date of birth*

MonthDayYear
Date
Child's age*
Gender*
Gender
Person filling out form*

NameRelation to child
Mother's name*

First NameLast Name
Father's name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Email*
example@example.com
How did you hear about TLC?*
How did you hear about TLC?*
Reason for evaluation and personal goals/main concerns you'd like to see addressed*
What is your availability for an evaluation and therapy? We schedule appointments Monday-Thursday 9 AM - 6 PM *
Who does the child live with?*
List any brothers or sisters and their ages.
What languages are spoken at home? What languages does your child speak, and what is their primary language?*
Is there any history of speech, language, hearing, feeding problems, learning issues, or delays in other family members?*

YesNo
Please explain.
Child's school*
Type n/a if not in school
Child's grade*
type n/a if not in school
Diagnosis (Please indicate any medical diagnoses or medical conditions)*
At what age did you first have concerns about your child's feeding?*

	Please list all the foods that your child accepts in each category
Protein
Dairy
Vegetables
Fruits
Grains
Other

	Top 5 Favorite Foods/Drinks
1
2
3
4
5

	Top 5 LEAST Favorite Foods/Drinks
1
2
3
4
5

	Top 5 Goal Foods/Drinks
1
2
3
4
5

Insurance Information
Name of Insured

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

MonthDayYear
Date
Social Security Number
Employer
Health Insurance (We are not in network with Medicaid.)
Policy / Member ID:
Provider Service Number:

Area CodePhone Number
Group #:
Please upload a copy of the front and back of your insurance card.

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Please upload a copy of your driver's license.

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Consent
I have checked with my insurance company prior to this therapy visit and assert that I have obtained the necessary information regarding limits of coverage, co-pays and co-insurance.*
I hereby give Therapeutic Learning Center, LLC permission to evaluate and treat my child, and understand there will be written, oral, and electronic communication between care providers/physicians, insurance companies. Certification or licensing and quality assurance may review my child's records. I understand that all practices of confidentiality will be followed within use of the information gathered.*
I give Therapeutic learning Center, LLC permission to submit bills directly to the insurance carrier.*
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and/or webspace.*
Permission Slip, Indemnification, Medical Agreement, and Grant of Rights
I hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Clinic ("clinic"). I understand that the clinic is completely voluntary. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this clinic. I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the clinic.

If any emergency medical procedures or treatments are required during the clinic, I hereby consent to the staff of TLC’s clinic, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter.

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.

The Undersigned expressly agrees that the foregoing Release, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.
I have read and agree to follow Therapeutic Learning Center, LLC Permission Slip, Indemnification, Medical Agreement and Grant of Rights*
Signature*

Clear
Payment and Attendance Policy

Please read carefully and initial to indicate you understand and agree to each policy
ATTENDANCE

I understand that TLC has an attendance policy of 75%, meaning my child will be present for at least 3/4 sessions or attend virtually whenever unable to come to the clinic to maintain this attendance rate.

If my child's attendance falls below 75%, my child may be placed on hold and contacted when we have cancellations only.

I understand that if I miss 2 consecutive appointments without notice that my child will automatically be removed from the therapy schedule.
I understand that TLC requires a current annual doctor's referral and initial hearing screening for speech services to take place.
Initials*
CANCELLATION FEES

I understand that I will be charged a LATE CANCELLATION/No-Show fee of $75 if I fail to give at least 24- hour notice prior to canceling my appointment. If a make-up session is scheduled within the same week, this fee will not apply.

I understand that a "consult fee" of $20 per 15 min will apply if my child's therapist is asked to participate in a phone call or conference for more than 20 minutes.
Initials*
INSURANCE

I understand that TLC is only in network with BCBS, United Healthcare, and Aetna private insurance plans. TLC is in network with the following BCBS plans: HMO Louisiana HMO/POS, OGB MagLocal Plus - PrefCare, OGB MagOpenAccess - PrefCare, OGB Pelican HRA/HSA PrefCare, OGB Preferred Care, Preferred Care PPO. TLC is OUT OF NETWORK with the following plans: Medicaid, Abbeville General, Blue Connect HMO/POS, Community Blue HMO/POS, OchPlus, OGB MagLocal – BlueConn, OGB MagLocal BR - CommBlue, Precision Blue HMO/POS, Signature Blue HMO/POS, TQHN.

By initialing below, I understand that if I do not have one of the plans listed above, my child will be charged private rates for services as follows: (evaluation $250-$400, 60 min session $125, 45 min session $100, 30 min session $68).

I understand that I am responsible for knowing my co-payment amount and deductible amount and if my plan is "in network". I understand that if insurance information is not available or you do not have insurance, PAYMENT IS DUE IN FULL (see above prices) unless other arrangements have been approved by the administration.

As a courtesy to our clients, we will verify and file your insurance; however, THIS IS NOT A GUARANTEE OF COVERAGE OR PAYMENT. We strongly suggest that you read your policy manual as it pertains to therapy coverage. Many insurance companies have stipulations, such as usually & customary fees (UCR), limited therapy sessions, limited reimbursable amounts per session, deductibles, co-payments, supplies, etc. Such stipulations should be indicated in your policy manual. YOU ARE RESPONSIBLE FOR AMOUNTS NOT COVERED by your insurance.
Initials*
PAYMENT FOR SERVICES

I understand that "Fusion" will email me an invoice as frequently as insurance claims are approved and that TLC has no control over the approval period. Services can be paid electronically via the invoice emailed to you. Due to our HIPAA compliant platform, the invoice is only available for 7 days.

I understand that my child’s weekly appointment time will not be guaranteed if payments are not received for services within 7 days of the date of invoice. This applies to children seen at the clinic and at school.
I understand that Therapeutic Learning Center has the right to discharge my child if payment for service is not received within the month of services provided. Payment for services is expected following each session or at the time of service.

I understand that if payments are received past 30 days from the date of invoice, a $10 late fee will apply. If payments are received 45 days or more from the date of service, a $20 fee will apply. Any balance 60 days or more will be turned over to an OUTSIDE COLLECTIONS SERVICE.

If collections services or an attorney is employed to collect payments due, I will also be responsible for interest and expenses, including but not limited to costs and attorney's fees.
Initials*
OUT OF OFFICE FEES

I understand that I will be charged a $20 out of office fee if my child is seen OUTSIDE OF THE THERAPY CLINIC SUCH AS A SCHOOL OR DAYCARE.

I understand that it is my responsibility to notify my child’s therapist or the front office if my child is not at school or daycare for the day the therapist is scheduled to see my child.

A no-show fee of $50 will be charged if your child is not at school or daycare and the therapist was not notified.

I understand that I will provide the office with a credit card to keep on file for payment when my child is seen outside of the therapy clinic such as school or daycare.
Initials*
CANCELLATION FEESI understand that I will be charged a LATE CANCELLATION/No-Show fee of $75 if I fail to give at least 24- hour notice prior to canceling my appointment. If a make-up session is scheduled within the same week, this fee will not apply.I understand that a "consult fee" of $20 per 15 min will apply if my child's therapist is asked to participate in a phone call or conference for more than 20 minutes.
- I understand that TLC is only in network with BCBS, United Healthcare, and Aetna private insurance plans. TLC is in network with the following BCBS plans: HMO Louisiana HMO/POS, OGB MagLocal Plus - PrefCare, OGB MagOpenAccess - PrefCare, OGB Pelican HRA/HSA PrefCare, OGB Preferred Care, Preferred Care PPO. TLC is OUT OF NETWORK with the following plans: Abbeville General, Blue Connect HMO/POS, Community Blue HMO/POS, OchPlus, OGB MagLocal – BlueConn, OGB MagLocal BR - CommBlue, Precision Blue HMO/POS, Signature Blue HMO/POS, TQHN - - By initialing below, I understand that if I do not have one of the plans listed above, my child will be charged private rates for services as follows: (evaluation $250-$400, 60 min session $125, 45 min session $100, 30 min session $68). - I understand that I am responsible for knowing my co-payment amount and deductible amount and if my plan is "in network". I understand that if insurance information is not available or you do not have insurance, PAYMENT IS DUE IN FULL (see above prices) unless other arrangements have been approved by the administration. - As a courtesy to our clients, we will verify and file your insurance; however, THIS IS NOT A GUARANTEE OF COVERAGE OR PAYMENT. We strongly suggest that you read your policy manual as it pertains to therapy coverage. Many insurance companies have stipulations, such as usually & customary fees (UCR), limited therapy sessions, limited reimbursable amounts per session, deductibles, co-payments, supplies, etc. Such stipulations should be indicated in your policy manual. YOU ARE RESPONSIBLE FOR AMOUNTS NOT COVERED by your insurance.
- I understand that "Fusion" will email me an invoice as frequently as insurance claims are approved and that TLC has no control over the approval period. Services can be paid electronically via the invoice emailed to you. Due to our HIPAA compliant platform, the invoice is only available for 7 days. - I understand that my child’s weekly appointment time will not be guaranteed if payments are not received for services within 7 days of the date of invoice. This applies to children seen at the clinic and at school. - I understand that Therapeutic Learning Center has the right to discharge my child if payment for service is not received within the month of services provided. Payment for services is expected following each session or at the time of service. - I understand that if payments are received past 30 days from the date of invoice, a $10 late fee will apply. If payments are received 45 days or more from the date of service, a $20 fee will apply. Any balance 60 days or more will be turned over to an OUTSIDE COLLECTIONS SERVICE. - If collections services or an attorney is employed to collect payments due, I will also be responsible for interest and expenses, including but not limited to costs and attorneys’ fees.
- I understand that I will be charged a $20 out of office fee if my child is seen OUTSIDE OF THE THERAPY CLINIC SUCH AS A SCHOOL OR DAYCARE. - I understand that it is my responsibility to notify my child’s therapist or the front office if my child is not at school or daycare for the day the therapist is scheduled to see my child. - A no-show fee of $50 will be charged if your child is not at school or daycare and the therapist was not notified. - I understand that I will provide the office with a credit card to keep on file for payment when my child is seen outside of the therapy clinic such as school or daycare.
- I understand that TLC has an attendance policy of 75% meaning my child will be present for at least 3/4 sessions or attend virtually whenever unable to come to the clinic to maintain this attendance rate. If my child's attendance falls below 75%, your child may be placed on the "stand by list" contacted when we have cancellations only. - I understand that if I miss 2 consecutive appointments without notice that my child will be removed from the therapy schedule. - I understand that TLC requires a current annual doctor's referral for OT services to take place.
I have read and agree to follow all Therapeutic Learning Center, LLC attendance and payment policies.*
Signature*

Clear
Divorced/Separated Parents and Custodial Arrangements

Therapeutic Learning Center, LLC does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on your former spouse or the child’s other parent. We will be happy to provide receipts for paid medical bills for you as requested.

FINANCIAL AGREEMENT AND GUARANTEE: I accept full and complete financial responsibility for all medical and/or therapeutic services rendered to the registered patient(s) and agree to any and all insurance co-payments, deductibles, and co-insurance that may be required under the terms of my medical insurance policies, as well as pay for any medical care that is considered a “non-covered” service under the terms of my medical insurance plan.
Signature

Clear
HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care.
Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing
care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the therapist.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. Signing below indicates you understand and agree to the terms of this HIPAA policy.
Signature

Clear
Date

MonthDayYear
Date
Child's name:

First NameLast Name
Guarantor's name:

First NameLast Name
Guarantor's Signature:

Clear
Should be Empty:

	Select if your child has received this service	Age of child at time of service	What was the reason for this service?
Speech Therapy
Occupational Therapy
Physical Therapy
Psychologist/Psychiatrist

	Age	Any problems?
Hold head up
Roll over
Sit alone
Crawl
Stand independently
Walk
Babble
Use single words
Combine words
Talk in sentences

	Age Introduced	Currently using? (select if yes)	Describe any difficulties your child had with this stage
Breast feeding
Bottle
Cup with spout
Straw
Open cup
Spoon (by caregiver)
Spoon (by child)
Finger feeding
Feeding tube

	Age introduced	Any trouble transitioning to these textures?
Smooth Purees
Chunky Purees
Table foods: Soft Solids (puffs, fruit cubes, etc.)
Table foods: Hard/Chewy Solids (meat, raw vegetables, etc.)

	Preferred	Not Preferred	Comments?
Sweet
Sour
Bland
Salty
Spicy
Smooth purees
Chunky purees
Soft solids
Hard solids
Hot foods
Warm foods
Room temperature foods
Cold foods

Feeding Intake Form

Prenatal/Birth History

Medical History

Developmental History

Feeding History

Alternative Nutrition

Mealtimes

Insurance Information

Consent

Permission Slip, Indemnification, Medical Agreement, and Grant of Rights

Payment and Attendance Policy

Divorced/Separated Parents and Custodial Arrangements

	Never	Sometimes	Often	Always
Arches back
Coughs
Chokes
Cries
Drools
Eats too fast
Easts too slow
Fails to chew food
Gags
Gets down from table
Holds food in mouth
Nasal regurgitation
Pockets food
Reflux
Refuses to open mouth
Refuses to eat
Spits out food
Stuffs mouth
Throws food
Turns head away
Vomits
Wet vocal quality after eating