INITIAL INTAKE FORM. Date Patient Information: M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB

Size: px

Start display at page:

Download "INITIAL INTAKE FORM. Date Patient Information: M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB"

Frederick Dawson
5 years ago
Views:

INITIAL INTAKE FORM Date Patient Information: Referring Physician Patient s Primary Care Physician M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB ( )

1 INITIAL INTAKE FORM Date Patient Information: Referring Physician Patient s Primary Care Physician M F - - / / / Patient s Name (last, first, middle) Sex Social Security Number Age Yrs/Months DOB ( ) - - Home Address Apt # Area Code Phone Number 2 nd Number Payment Method: Cash Check Visa/MasterCard City, State Zip Code (CIRCLE ONE) Insurance Contract Address: Insurance Company or Contracting Agency Policy Number Family and Employment Information (if applicable): M F Parent s Full Name Social Security Number DOB Sex ( ) - Home Address Area Code Phone Number ( ) - City, State Zip Code Employer Work Number Supervisor s Name and Position Employer s Address City, State Zip M F Parent s Full Name Social Security Number DOB Sex ( ) - Home Address ( ) - City, State Zip Code Employer Work Number Supervisor s Name and Position Employer s Address City, State Zip School ( ) - Address Phone Number Agency Case Mgr ( ) - Concerns:

2 PATIENT HISTORY BIRTH HISTORY HEALTH PROBLEMS DURING PREGNANCY DIABETES MEASLES TOXIMIA PREMATURE LABOR STREP RESPIRATORY OTHER USE OF DRUGS ALCOHOL PERSCRIPTIONS ADDTL INFO LABOR AND DELIVERY MOTHER S AGE VAGINAL C-SECTION EMERGENCY? Y N FORCEPS VACUUM OTHER POSTNATAL CARE CONDITIONAL BIRTH: PREMATURE? Y N (IF YES) GESTATIONAL AGE: APGAR SCORE NICU OTHER VENTILATOR? Y N (IF YES) HOW LONG? JAUNDICE HEART PROBLEMS POOR SUCK BIRTH WEIGHT ANY KNOWN DIAGNOSIS/GENETIC DISPRDERS (EG. DOWNS SYNDROME) ANY OTHER MEDICAL COMPLICATIONS: DEVELOPMENTAL HISTORY PLEASE LIST THE APPROXIMATE AGE THE CHILD ACCOMPLISHED THE FOLLOWING: SIT ALONE ROLL OVER CRAWL WALK BABBLE SAY FIRST WORDS PUT 2 WORDS TOGETHER POTTY TRAINED THUMB SUCKER/PACIFIER: Y N HOW LONG HAND PREFERENCE: LEFT RIGHT DOES YOUR CHILD HAVE PROBLEMS WITH ANY OF THE FOLLOWING: CHEWING SWALLOWING BALANCE CRAWLING WALKING SITTING JUMPING PICKING UP SMALL THINGS THROWING KICKING CATCHING BABBLING TALKING BEHAVIOR

3 MEDICAL HISTORY (Answer with Y for Yes or N for No ) MEASLES MUMPS PNUEMONIA CHICKEN POX BRONCHITIS BPD REFLUX TONSILLITIS ECZEMA RASHES MRSA FREQUENT COLDS SINUSITIS ASTHMA OTHER BREATHING DIFFICUTLIES VOCAL NODULES/POLYPS HIGH FEVER SCARLET FEVER MENINGITIS ENCEPHALITIS VISION HEARING SLEEPING DIFFICULTIES XEROSTOMIA (DRY MOUTH) OTHER SEIZURES: Y N FREQUENCY: EAR INFECTIONS FREQUENCY LAST EAR INFECTION TREATMENT METHOD ALLERGIES (PLEASE BE SPECIFIC): DO YOU HAVE AN EPI-PEN HEAD INJURIES? Y N (IF YES) WHEN: PLEASE PROVIDE DETAILS OF INCIDENT AND SEVERITY: LIST ANY HOSPITALIZATIONS SURGERIES EAR OR PE TUBES: Y N STILL IN PLACE: Y N CENTRAL LINE SINAL INFUSIONS G-TUBE HEART REPAIR TRACH SHUNT TONSILLECTOMY ADENOIDECTOMY APPENDECTOMY CLEFT LIP/PALATE REPAIR OTHER ANY TESTING PERFORMED MRI CT SCAN GENETIC TESTING XRAYS OTHER CURRENT MEDICATIONS AND PURPOSE:

4 EDUCATIONAL HISTORY DO YOU HAVE COPIES OF YOUR CHILD S MOST RECENT REPORTS (504, MET, IEP, ETC) Y N PLEASE LIST ALL SCHOOLS THAT YOUR CHILD HAS ATTENDED, WITH DATES (INCLUDING PRE-SCHOOL) SCHOOL: DATE: SCHOOL: DATE: SCHOOL: DATE: SOCIAL HISTORY DESCRIBE YOUR CHILD S STRONG LIKES: DESCRIBE YOUR CHILD S STRONG DISLIKES: PLEASE DESCRIBE SPECIFIC TOYS OR ACTIVITIES THAT MOTIVATE YOUR CHILD: DESCRIBE YOUR CURRENT CONCERNS ABOUT YOUR CHILD (AT HOME, SCHOOL, PLAY, ETC):

5 FAMILY AND ENVIRONMENT HISTORY CHILD LIVES WITH: LEGAL GUARDIAN NAMES: BIRTH PARENTS FOSTER PARENTS MOTHER FATHER ADOPTIVE PARENTS PARENT & STEP-PARENT OTHER NAMES & AGES OF SIBLINGS: NAMES & TYPES OF PETS: FAMILY HISTORY IS THERE ANY KNOWN HISTORY OF THE FOLLOWING IN THE IMMEDIATE OR EXTENDED FAMILY: AUTISM/PDD ADHD LEARNING DISABILITIES HEARING LOSS STUTTERING SPEECH/LANG DELAYS VISION AND HEARING HISTORY VISION EXAM: Y N RESULTS HEARING EXAM: Y N RESULTS PREVIOUS EVALUATIONS AND THERAPY HAS YOUR CHILD HAD ANY EVALUATIONS BY A MEDICAL OR EDUCATIONAL SPECIALIST? PLEASE DESCRIBE: HAS YOUR CHILD EVER RECEIVED PT OT SLP INCLUDING SCREENING AND EVALUTATION? Y N DATE OF SCREENING/EVAL: NAME OF PRACTICE/SCHOOL: EQUIPMENT/ORTHOTICS:

6 BEHAVIORAL CHARACTERISTICS COOPERATIVE WILLING TO TRY NEW ACTIVITIES SEPERATION DIFFICULTIES STUBBORN POOR EYE-CONTACT DESTRUCTIVE/AGGRESSIVE INAPPROPRIATE BEHAVIOR ATTENTIVE RESTLESS WITHDRAWN SELF-ABUSIVE BEHAVIOR EASILY DISTRACTED/SHORT ATTENTION PLAYS ALONE FOR REASONABLE LENGTH OF TIME EASILY FRUSTRATED/IMPULSIVE IS THERE ANYTHING ELSE ABOUT YOUR CHILD THAT YOU D LIKE US TO KNOW (INCLUDING PRECAUTIONS)?

7 Thank you for choosing Therapy Tree as your therapy provider. We are committed to your successful treatment. Please understand that in order to provide the best treatment and meet your needs, we need you to accept total financial responsibility. We consider payment of your bill an important part of your treatment. The following is a statement of our Financial Policy that we ask that you read and sign prior to any treatment. THERAPY TREE FINANCIAL POLICY All patients (or parents) must complete our Patient Intake Information form before seeing a treatment provider. FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, and VISA/MASTERCARD. WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL. CERTAIN PARTIES MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. Regarding Insurance Your insurance policy is a contract between you and your insurance company; we are not party to that contract. We may accept assignment of insurance benefits your second visit. However, we do require a portion of the bill to be paid at time of service. The balance is your responsibility whether your insurance pays or not. We cannot bill your insurance company unless you give us your complete insurance information. In the event we do accept assignment of benefits we may ask that you be pre-approved on out extended payment plan or provide a credit card with authorization to bill that account for the balance. If you insurance company has not paid your account in full within 60 days, the balance will be automatically transferred to you, your credit card, or to the extended payment plan. Please be aware that some, and perhaps all, of the services provided may not be covered services and thus considered reasonable and necessary under your insurance policy. Regarding insurance plan where we are a participating provider, all co-pays and deductibles are due at time of treatment. In the event that your insurance coverage changes to a plan where we are not a participating provider, the provisions in the paragraph above apply. Usual and Customary Rates Therapy Tree is committed to providing the best treatment for our patients, and we continually maintain that our fees remain competitive with like providers in our area. You are responsible for full payment of our established fee regardless f any insurance company s arbitrary determination of usual and customary rates. Adult & Minor Patients Adult patients are responsible for full payment at time of service. The adult accompanying a minor and the parents or guardians of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless arrangements have been made in advance to use an approved credit plan or cash, check, or credit card makes payment. I understand that the services or items that I have requested to be provided to me not be covered under the Arizona Medical Assistance Program as being reasonable and medically for my care. I understand that the Arizona Department of Health or its health-insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I requested and receive id these services or items are determined not to be reasonable and medically necessary for my care. Certificate: I have read and agree to the terms of this FINANCIAL POLICY. X Signature of Patient or Responsible Party Date

8 CLIENT ACKNOWLEDGEMENT STATEMENT I understand that, in the opinion of Therapy Tree, the services or items I have requested to be provided to me beginning may not be covered by the health insuring agent as being reasonable and medically necessary for my care. I understand that the health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care. AUTHORIZATION for RELEASE OF INFORMATION I authorize the release of any medical or other information necessary to process any claims for services rendered by Therapy Tree. I authorize payment of medical benefits to Therapy Tree for services rendered. X Patients, Insured s, or Authorized Signature Date Please give 24-hour notice if you need to cancel your therapy session. We understand that certain circumstances will not always allow this type of notice, but if all possible, please give the front office as much notice as possible. Thank you for your cooperation!

14 CONSENT TO TREAT MINOR CHILDREN Please print all information I,, parent or legal guardian of, born, do hereby consent to any Speech, Occupational, or Physical Therapy care for the welfare of my child while said child is under the care of. This authorization is effective from to. Signature of Parent or Legal Guardian Witness Signature Witness Name (please print) This consent form should be taken with the child to the therapist's office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent but is not required. Family address Telephone: Father home work Mother home work Child's Birthdate Child's Physician Phone #

Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI

PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone: