New Client Intake Packet

New Client Intake/Pre-Service Provider Orientation Packet

Thank you for choosing "Watch Me Grow" Pediatric Therapy for your child's therapy needs. Our mission is to provide the highest quality therapy services individualized for your child. Our skilled staff of pediatric therapists work to enhance your child’s development in the areas of sensory integration, sensory processing, motor coordination, self-care skills, balance, mobility articulation, expressive/receptive language, speech/ language delay, oral motor skills and more! We hope to act as a guide in helping you put together the pieces and come up with the best possible treatment plan for your child’s specific needs. If you have any questions, please feel free to contact the office at (480)-506-0016, or email info@watchmegrowtherapy.com.
Child's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Preferred contact method

CellEmailText
Date of Birth*
Gender*

MaleFemale
Mother's Name*
Father's name*
Email*
Child lives with:

Both parentsMomDadGrandparentsOther guardian
Cross-streets
Emergency Contact Name and Number ( besides both parents)*
Please list your child's availability*
Please check the services your child is interested in:*

Speech TherapyOccupational TherapyRespiteHabilitationAttendant Care
Funding Source

DDD/ALTCSBCBSPrivate PayESAOther
Child's School and Grade*
Please list some of your child's strengths*
MEDICAL HISTORY & DEVELOPMENTAL HISTORY
Diagnosis*
Previous hospitalizations *
Please list any allergies*
Pregnancy/Birth ( Complications before, during or after)*
Full-term? *
Birth Weight*
Does your child have a history of ( please mark)*

SeizuresAsthmaHead injuryVision loss/CorrectionHearing LossOther
Current Medications*
At what age did your child first.....
Roll over
Sit Alone
Crawl
Stand Alone
Walk Alone
Eat Solid Foods
Drink from a cup
Say first words
Feed-self
Potty trained?
Dominant Hand*

RightLeftUnknownOther
Is there anything else the therapist should know about your child? ( e.g. behaviors, sensitivities, fears) *
Consent: I understand I have read and understand Watch Me Grow's Cancellation Policy*

YESNO
Privacy Practices: I consent to necessary examination/evalaution and/or treatment for my child by Watch Me Grow, LLC staff*

YESNO
Release of Medical Information: I consent to the release of the following medical information:*

Therapy EvaluationsTherapy progress reportsTherapy soap notesMedical recordsEducational recordsOther
PEDIATRCIAN INFORMATION
Physician Name*
Physician Phone Number*
Medical Office Name
DDD INFORMATION
Support Coordinator Name*
Support Coordinator telephone number or email
PRIVATE INSURANCE

You may have AHCCCS, ALTCS or private insurance. Sometimes you may have a combination. Coordination of benefits occur when you have multiple heath plans. AHCCCS is the payer of last resort. This means AHCCCS will be used as a source of payment for covered servcies only AFTER your private insurance and other sources of payment have been used.

I understand that I am responsible for any and all bills incurred and that any third party coverage of insurance is for the purpose of assisting me with my responsibility. I understand that if failure or refusal to pay results in collection and legal fees. I understand that I am responsible for any collection, legal or additional fees incurred.
I have reviewed and understand Watch Me Grow's Private Insurance Policy*

YESNO
Signature

Clear
Policy Holder's Name
Policy Holder's Date of Birth
Employer
PRIVATE INSURANCE COMPANY INFORMATION
Name of Insurance Carrier
Insurance Carrier Contact Number
Insurance Effective Date
Patient ID
Group Number
ID Number
Billing Address including City and Zip Code
I have received and reviewed the Notice of Privacy Acts*

YesNo
CANCELATION POLICY

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable, however, advance notification allows us to fulfill other patients scheduling needs and keeps Watch Me Grow LLC operating at its most efficient level. Due to our one-on-one, missed appointments are a significant inconvenience to your therapist, the clinic, and other patients.

We reserve your appointment time just for you. We do not double book our patients so that we may provide optimum treatment outcomes. 24 hour notice allows us to place another patient in your cancelled appointment period.
After cancelling three appointment in one quarter, we will no longer be able to hold your specified appointment time each week. We can discuss options for week to week scheduling. This is not a guaranteed appointment each week.
After two consecutive cancellations, without rescheduling attempts, we will need to address the situation and see if there is a better time for your weekly appointment
ELECTRONIC SIGNATURE
Any signature (including any electronic symbol or process attached to, or associated with, a contract or other record and adopted by a Person with the intent to sign, authenticate or accept such contract or record) hereto or to any agreement or document related to this intake packet, and any record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, and the parties hereby waive any objection to the contrary.
Signature*

Clear
Should be Empty:

New Client Intake/Pre-Service Provider Orientation Packet