GCMT Adult Intake

The George Center Foundation Adult Paperwork
Music. Healthcare. Perfect Harmony.

The entire staff at The George Center Foundation would like to thank you for choosing us and welcome you to our family. It is our goal at The George Center to provide you with outstanding services, support, and communication regarding your family’s needs. We provide an environment that is encouraging, well-informed, enjoyable, and sincere. We want you to be an integral and active participant in your child’s therapy and learn how to provide an environment for your child and family that will support his/her development. We also want you to be involved in establishing goals, treatment planning, home exercises, and discharge planning. Our intention is to move towards a level of independence within everyone’s abilities.
Jacob's Ladder School and Therapy CenterPrecision ChiropracticReclifBuilding BridgesNorth Fulton Wellness AllianceOther
Client Information
Full Name*

First NameLast Name
Preferred name
Date of Birth

MonthDayYear
Date
Gender
Diagnoses/ DX Codes
Primary Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Secondary Contact

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact

First NameLast Name
Emergency Phone Number

Area CodePhone Number
How did you hear about us?*
If other, please specify here:
Primary Physician Name

First NameLast Name
Primary Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Have you been approved for Family Support Funding or other scholarships/grants through a third party source? If so, will you be using these funds to cover your music therapy services? If yes, please indicate the contact information and instructions on how we are to invoice them.
What are your favorite activities?
What are your priorities in coming to The George Center?
What are your favorite songs and/or type of music? Are there any particular artists/musicians or music genres that you are interested in?
Do you have interest in a particular instrument?
Patient's Legal Guardian (if applicable):
Have you had previous music lessons or music therapy elsewhere? If yes, please describe:
Family History
With whom do you reside?
Is there any information regarding your family situation that we should know?
What is the primary language spoken in your home?
Medical History
Please list any recent hospitalizations
Current medications (Please list dosage, frequency & reason for each medication):
YesNo
If yes, please describe:
Are you able to communicate verbally?
If no, what is your preferred mode of communication? i.e. PIX, ASL, etc...
What typically calms/soothes you?
Are their any medical/behavioral issues that we need to be aware of? i.e., seizures, biting or self-injurious behaviors
YesNo
If yes, please list and describe expected reactions to allergy and rescue medication protocol.
Do require any physical assistance or use assistive equipment? i.e. a wheel chair, walker, etc...
Have you experienced any recent trauma or change in life circumstances? If so, please describe:
IIs there anything we should know about your gross motor, fine motor, sensory, expressive language or social/emotional needs? If so, please describe:
Are you currently enrolled in school or support service? If yes, please list where do you attend, what days you are there and any services you currently receive services through your school or a support service
Are you enrolled in any community activities? If so, please describe.
CONSENT TO TREAT This Consent to Treat Agreement is between The George Center for Music Therapy, Inc., and the patient listed above. I do consent for The George Center for Music Therapy, Inc. to provide my child with Music Therapy services. I consent to care and treatment falling under the practice guideline of the American Music Therapy Association (AMTA), the Certification Board for Music Therapists, and the State of Georgia. I acknowledge that there is always a risk of injury with any therapy involving physical activities. This agreement constitutes the entire agreement between the parties regarding the matters contained herein. This agreement may be signed electronically, in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. I understand and agree that they are jointly and severally liable to The George Center for Music Therapy, Inc. with regard to all obligations contained within this agreement.

I agree to the Consent to TreatI do not agree
FINANCIAL AND INSURANCE POLICY We thank you for choosing us as your music therapy provider. We are committed to your treatment being successful. The following is a statement of our financial policy that we would like for you to read carefully read and agree to as evidence of your understanding prior to any treatments. We must emphasize that our relationship is with you, not your insurance company. We file the insurance claim as a courtesy to our patients . All charges are ultimately your responsibility from the date services are rendered. Our service is not always a covered benefit in all contracts. It is important that you read and understand YOUR health insurance policy and its requirements for coverage. We are not responsible for knowing the requirements of your plan. Benefits will be verified upon receipt of your insurance information. You will be made aware of any estimated out-of-pocket expenses prior to the start of services. Information obtained from insurance companies is not always a guarantee of payment. We strive to keep open communication in regards to insurance payment, but it is also important that you review your Explanation of Benefits related to the coverage of our ongoing services as well.Families will inform The George Center for Music Therapy, Inc. of any changes regarding insurance. Families assign benefits for filed claims to be paid to The George Center for Music Therapy, Inc. Any payment sent directly to the family, intended to cover therapy services provided by The George Center for Music Therapy, Inc., should be given to the front office. I understand and agree with the above statement:

YesNo
The usual and customary rate for services is billed to insurance. If we bill your insurance and you have a deductible, the full amount applied to your deductible will be billed to you. The George Center for Music Therapy, Inc. can not accept Medicaid, therefore families are responsible for all co-pays, co-insurances, and deductible expenses associated with each date of service. Please contact us directly if you are experiencing financial hardship. The George Center for Music Therapy, Inc. accepts cash, check, VISA, MASTERCARD, Discover, and American Express. There is a $50 fee for all returned checks. I understand and agree with the above statement:

YesNo
We submit claims to insurance within one month of service dates. If payment has not been received within 60 days, the family will be responsible for the balance. If insurance makes payment, the family will be reimbursed any money that was paid for these services. If a family receives a bill that is not paid within 30 days of receipt of invoice, there will be a $20.00 late fee added, and services risk being put on hold. I understand and agree with the above statement:

YesNo
The George Center for Music Therapy, Inc. will file all insurance claims as an out-of-network provider. Deeming Waiver (Katie Beckett) and SSI Medicaid will not cover music therapy services. We are not contracted with CMO plans (Amerigroup, Peachstate, or Wellcare). If authorization is required, therapists will submit based on need. Services will be administered after approval has been obtained. I understand and agree with the above statement:

YesNo
An initial evaluation for music therapy services is $150/hour. Evaluations are an out-of-pocket expense expected at the time of service. An initial evaluation will be needed for all children starting therapy with our facility. Most evaluations will last 1 hour. Music therapy clients are re-evaluated every 6 months for therapeutic consistency. Re-evaluations are also $150. If a family needs a re-evaluation for insurance or personal reasons, the rate will be $150/hr. Financial arrangements will be made prior to the time of evaluation. I understand and agree with the above statement:

YesNo
Yes (listed below)No
ATTENDANCE POLICY: Because of frequent no-shows and cancellations, The George Center for Music Therapy, Inc. has a policy that states that we require a 24 hour notice for cancellations. After a one-time occurrence, a $40 fee will be charged for EACH missed therapy appointment. We know that sickness occurs; therefore, if you think that you are sick the night before, please call us and give us notice so we may plan accordingly, and/or contact a family who is on stand by for a make-up session or on a waiting list for an evaluation or services. To that end, we require that a current credit card be placed on file at all times. You will be asked to fill out that form at your first session. We will run the no-show/last minute cancellation fee on the date of expected service. This ensures that our clinicians will still receive payment in full for their time and service in preparation for the missed therapy session. In the event of a cancellation, we will make every effort to reschedule as we want you to benefit from therapy. If you miss 3 consecutive weeks of therapy, we will make every attempt to hold that slot, but cannot guarantee this with an extended absence. The staff at The George Center for Music Therapy, Inc. strives to meet the scheduling needs of every family. If your therapy time does not work for you, please let us know. I understand and agree with this policy:

YesNo
ILLNESS POLICY The Board of Health considers the following signs to indicate communicable disease/illness: vomiting, fever over 100 degrees, diarrhea, sore throat, rash/swelling, red, or running eyes. Please be sure you are symptom free for 24 hours before resuming therapy. Please note that if you attend therapy and exhibit any of the above symptoms, it is at the therapist’s discretion to send you home in order to protect themselves and our other clients from infectious illness. I understand and agree with the above policy:

YesNo
YesNo
CONSENT FOR AUDIO/VISUAL RELEASE I give permission to be photographed/recorded by the therapists at The George Center for Music Therapy, Inc. These photographs/videos will be used for education and training purposes (i.e., clinical supervision, conference presentations), and may be used by The George Center for Music Therapy, Inc. for advertisement purposes (i.e., brochures, magazines, newspapers, social media). At no time will the patient’s full name be spoken during recordings and the patient’s full identity will remain confidential.

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YesNo
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Date of Acknowledgement:

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Signature
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The George Center Foundation Adult Paperwork

Music. Healthcare. Perfect Harmony.

Client Information

Family History

Medical History