Clone of Patient Information

2026 Patient Information

Please fill in the form below
Name*

First NameMiddle NameLast Name
Sex*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Patient is a Child

Please complete the following section:
Parent #1:

First NameLast Name
Parent #1 Email*
example@example.com
Parent #1 Phone

Area CodePhone Number
Parent #1 Employer:*
Parent #2 Name:

First NameLast Name
Parent #2 Email
example@example.com
Parent #2 Phone

Area CodePhone Number
Parent #2 Employer:
Marital Status
If parents are divorced, separated, or unmarried, please fill out this section: Who has physical custody?
Are there any legal restrictions that would restrict the non-custodial parent from consenting to treatment for the child or from obtaining information about the child’s treatment?
If yes, please explain and provide a copy of any legal paperwork that supports this restriction:
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If the patient is an adult

Please complete the following section:
Email
example@example.com
Phone Number

Area CodePhone Number
Employer
Name of Spouse (if applicable)
Spouse Phone Number (if applicable)

Area CodePhone Number
Physician Information
Patient Physician Name:*
Physician Practice Name:
Physician Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number:*

Area CodePhone Number
Consents
Consent for Treatment: I consent for therapists employed by GASLC and/or contracted therapists working for GASLC to provide my child or myself with speech-language, occupational, and/or physical therapy including assessment and intervention.*

YES
Initials*
As the parent or legal guardian of the patient, I give authorization for Parent #2 to bring my child to the evaluation/therapy sessions in my absence. I also give permission for the therapist to discuss the current treatment procedures and/or release records. This is in compliance with HIPAA 1996 and is designed to safeguard the privacy and security of the named patient’s health information.*

YESNOOther
Additional adults allow to bring my child to and from therapy and for the therapist to discuss the current treatment procedures with the people listed below.
Consent to Email Protected Health Information: I consent for employees and contracted therapists working for GASLC to send any and all protected health information regarding my child or myself via email, which includes but is not limited to: evaluations, treatment notes, weekly session updates, progress notes, etc.*

YESNOOther
Photo Release: I give permission for my child’s photograph to be used by Greater Atlanta Speech and Language Clinics (GASLC) on clinic bulletin boards, the clinic website, and official social media platforms. No names or identifying information will be used.*

YESNO
Attendance and Tardy Policies:
ATTENDANCE POLICY: We ask that you attend at least 75% of all scheduled appointments to keep your regularly scheduled weekly appointments. Consistency and carry-over is essential for your child to make progress. If you are not attending at least 75% of your weekly scheduled appointments, you may be moved to a ‘flex’ schedule. This will mean that you will be informed each week the days/times that we have open to see your child for therapy and will not hold a weekly scheduled session. Once attendance is again consistent, we will be happy to place you back on the regular schedule. Initials*
TARDY POLICY: Please arrive on time for all scheduled therapy sessions. Consistent timeliness helps your child receive the full therapeutic benefit each visit and allows our therapists to maintain an effective schedule for all patients. If you arrive 15 minutes late or more, the scheduled session will not occur. Sessions cannot be extended past the scheduled end time to make up for late arrival. If a family knows they will be late, you may call ahead; however, calling does not guarantee that the session can be accommodated. Frequent late arrivals may require a review of scheduling options, as repeated tardiness impacts your child’s progress and our clinicians’ ability to serve other families. Initials*
CANCELLATION/TERMINATION POLICY: I understand that GASLC reserves the right to charge a fee for any appointment that is not kept or not cancelled by giving 24 hours notice. Unforeseen circumstances are anticipated and will be handled on a case by case basis. If you plan to dismiss your child or yourself from therapy, a 2-week notification is REQUIRED unless otherwise agreed upon. Should you choose to end treatment without two-week notification, you will be responsible for paying for all services that would have been provided in those two weeks*
I UNDERSTAND THE CANCELLATION, ATTENDANCE, AND TARDY POLICIES*

I understand
Initialing below notifies GASLC that I agree to the above attendance, tardy, and cancellation/termination policies. Initials*
Insurance/Medicaid Information
Is the patient covered by Insurance:*

YESNO
If patient is covered by insurance complete the following information:

Primary Insurance Company:
ID #: Group #:
Primary Insured:
Relationship to Patient:
DOB of Primary Insured:
Customer Service Provider Phone Number:
Take Photo of Front of Insurance Card. If you cannot take a photo, you can upload a file in the next question and take a blank photo.*
Upload a photo or file of the front of your insurance card if you did not take a photo.

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Take Photo of Back of Insurance Card*
Upload a photo or file of the back of your insurance card if you did not take a photo.

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Cancelof
Is the patient covered by secondary insurance:*

YESNO
If patient is covered by secondary insurance, complete the following information:

Secondary Insurance Company:
ID #: Group #:
Primary Insured:
Relationship to Patient:
DOB of Primary Insured:
Customer Service Provider Phone Number:
I understand that if I have BOTH primary and secondary insurance policies that this makes my claims subject to coordination of benefits and subject to the rules and regulations of each separate policy. Initials*
Is the patient covered by Medicaid:*

YESNO
If patient is covered by Medicaid complete the following:
Medicaid #:
Take Photo of front of Medicaid Card:
Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage with * and assign directly to Greater Atlanta Speech and Language Clinics, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Greater Atlanta Speech and Language Clinics, Inc. to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature*

Clear
Relationship to Patient:*
Date*

MonthDayYear
Should be Empty:

2026 Patient Information

If Patient is a Child

If the patient is an adult

Physician Information

Consents

Attendance and Tardy Policies:

Insurance/Medicaid Information

Assignment and Release