Occupational Therapy Client Intake Form

Occupational Therapy Client Intake Form
Date

Month Day Year
Date Date Picker Icon
Client Name *

First Name Last Name
Gender:
Age:
Client Date of Birth:
Parent Name *

First Name Last Name

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone: *

Area Code Phone Number
Home Phone number:

Area Code Phone Number
Email: *

Confirmation Email example@example.com
Referred to our clinic by? *
Child's primary care physician: *
Phone Number:

Area Code Phone Number
Emergency contact: *

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship with Client:
Email: *
example@example.com
Diagnosis (Please indicate any medical diagnosis or medical condition below):
Reason for visit today and personal goals/main concerns you'd like to see improvement:

Guarantor Information
Guarantor:

First Name Last Name
Date of birth:

Month Day Year
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Relationship with client:
Social security number:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

Area Code Phone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer:
Insurance Information
Name of Insured:

First Name Last Name
Date of birth:

Month Day Year
Date Date Picker Icon
Social Security Number:
Employer:
Health Insurance
Policy/Member ID#:
Group#:
Provider Service#:

Area Code Phone Number
Please upload a copy of the front and back of your insurance card.

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Insurance Card Cancel of
Please upload a copy of your driver's license.

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Driver's License Cancel of

Feeding
Did your child have any feeding problems as an infant? Please describe:
Was your child bottle or breastfed and for how long?
Did your child have colic or reflux issues? Please describe:
Is your child a picky eater?
Current Diet tolerated:
Hearing:

Intact Impaired Aid Questionable
Vision:

Intact Impaired Aid Questionable
Has your child had any ear infection? How frequently?
Have they had their hearing tested? What were the results?
Does your child wear hearing aids?
Does your child have a vision impairment/wear glasses?

Medical information
Does your child have any allergies? Please list:
Please describe illnesses, medical complications, or hospitalizations that your child has had and when:
Surgeries, if yes, please explain:
Any other helpful information about your child that is important for us to know:

Consent and Policies
I give permission for photographs/video of my child to be used for treatment, education, documentation: *
I give permission for photographs/video of my child to be used for advertising, brochures and/or webspace: *
I have a prescription from my child's physician to authorize an initial evaluation for services. *
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 have read and agree to follow Therapeutic Learning Center, LLC office and financial policies. *
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, Permission Slip, Medical Agreement and Grant of Rights. *
Initials *
Out of the Office Therapy Fee

Therapeutic Learning Center is happy to see your child at school. The fee for out of office sessions is ten dollars ($10.00) for each visit/evaluation a child is seen at school or other location outside of our clinic, regardless of the appointment length (30 min, 45 min, or 60 min). This fee will be added to your co-pay or private pay fee.

I agree to be charged for the out of the office therapy visit fee for every visit my child is seen at school or location outside of the TLC clinic.

I agree to place a credit card on file with the TLC administrator so that my child's services can be charged following each visit.
12 Week Therapy Session Duration/No-Show/Cancellation Policy

Please read this carefully.

12 Week Therapy Session Duration

As of January 1, 2019, Therapeutic Learning Center will be changing the way we provide our therapy sessions in regards to the duration of services. We will be providing therapy in 12 week intervals. At the end of 12 weeks, you will meet with your therapist to discuss your child’s progress, attendance (see below for the 75% attendance requirement), and together, determine whether continued services will benefit your child.

No-Show/Cancellation

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable; however, advance notification allows us to fulfill other client’s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 30, 45 & 60-minute treatments, missed appointments are a significant inconvenience to your occupational therapist, the clinic, and other clients. For the benefit of our clients and to optimize our therapist’s time, advanced notice for cancellations is requested.

We reserve your child’s therapy appointment times on a one to one basis. As a clinic policy, we do not double-book our clients so that we may provide optimum treatment for all our clients. We require 24-hour notice for all cancellations as it allows us to place another client in your cancelled appointment period to receive needed treatment. If the appointment is not cancelled outside of 24-hours, your appointment will be considered a “no show” and a $50 no show fee will be reflected on your account. We require a 75% attendance rate to keep your weekly appointment time. If the appointment can be rescheduled within the week, the missed appointment will not count against your attendance rate. We will allow for one “pass/missed appt” if the appointment is not cancelled outside of the 24 hours if your child is sick and missing the appointment is unavoidable.

After missing two consecutive appointments without notice or if you fail to maintain the 75% attendance rate, we reserve the right to place your child on a “stand by list” and services will be placed on hold or discharged.
Thank you for providing our office and our clients with this courtesy. Signing below indicates you understand and agree to the terms of this policy.
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Occupational Therapy Client Intake Form

Guarantor Information

Insurance Information

History

Feeding

Medical information

Consent and Policies