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*
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
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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If yes, please upload a copy of the prescription for Feeding Therapy services. (If no, we need this document for regular sessions. The pediatrician can write a prescription for speech services as long as the child has attended their most recent annual appointment.)

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Consent and Policies:
I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and/or webspace.
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.
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 all parts carefully
-I understand that I will be charged a LATE CANCELLATION fee of $25 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 I will be charged a LATE CANCELLATION fee of $35 if I cancel within 4 hours of my appointment time. - I understand that I will be charged a NO-SHOW fee of $50 if I fail to show for my appointment. - 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. *
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.
Child's name:

First NameLast Name
Guarantor's name:

First NameLast Name
Guarantor's Signature:

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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 and Policies:

Payment and Attendance Policy

	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