Email INSURANCE INFORMATION As a courtesy we will bill your primary insurance carrier if you provide ALL necessary information (such as insurance cards with their CORRECT billing address and REFERRALS). Co-pays are collected for each visit at the time of service. Statement of Financial Responsibility I understand my insurance carrier may not approve or reimburse my medical services in full due to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessity. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles and co-insurance. PRIMARY INSURANCE Insurance Name: * Claims Address: * Policyholder Name: * Policyholder DOB: * Marital Status: * Policyholder Social Security #: * Policyholder ID #: * Patient ID #: * Group #: * Your First Name: * HIPPA Required Field. Your Last Name: * HIPPA Required Field. Your Email * HIPPA Required Field. Signature of Legal Guardian: * For billing purposes we require this form to be fully completed. We reserve the right to reschedule any appointments due to incomplete forms or tardiness. Thank you for your cooperation. Name Adult Intake Packet Date of evaluation: * Patient Information First Name: * HIPPA Required Field. Last Name: * HIPPA Required Field. Email: * HIPPA Required Field. Date of Birth: * Social Security #: * Marital Status: * Married Single Divorced Widowed Address: * City: * State: * Zipcode: * Specialty Doctor/Phone: Fax #: Primary/Family Physician: Primary/Family Physician Phone: Fax #: Employer: Employer Address: Employer City: Employer State: Employer Zipcode: Work Status: * FT PT Retired Student Unemployed Disabled Gender * Body Part RX Date: Date of Injury/Onset: The onset date is date the first injury occurred. Diagnosis: Emergency Contact Name: * Emergency Contact Phone: * Past Medical History Questionnaire Reason for Therapy: * Date of Injury/Onset: The onset date is date the first injury occurred. Have you ever received therapy for the condition mentioned above? * Yes No Treatment received: Previous Treatment: Successful Unsuccessful Can you be/are you pregnant?: * Yes No Do you now or have you ever had any of the following conditions? Conditions: Arthritis Hearing Loss Osteoporosis Depression High Blood Pressure Anxiety Heart Disease Substance Abuse Heart Attack Diabetes Pace Maker Anemia Vascular Disease Hypersensitivity to Hot/Cold Stroke Swelling in Ankles Asthma Deep Vein Thrombosis (DVT) Conditions (continued): Shortness of Breath Seizures/Epilepsy Chronic Cough Metal in Body/Surgical Implants Fainting Spells Cancer/Tumor Thyroid Problems Recent Weight Loss/Gain Headaches Current Infection(s) Head Injury/Concussion Tuberculosis Hernia Hepatitis Kidney/Previous Fractures Previous Surgeries Other If you answered “yes” on any of the above, please explain and give approximate date(s): Do you have any allergies: Yes No Are you presently taking any medications?: * Yes No Communication & Language Use Uses Words: * Yes No Uses Sentences: * Yes No Omits small words (of, the, and, etc.): * Yes No Words that seem to be difficult: Easier words: Most difficult communication activities: Understands TV or radio: Yes No Reads/Understands newspaper: * Yes No Follows simple requests or instructions: * Yes No Relies on Gestures: * Yes No Relies on other means of communication: * Yes No Do family members try to fill in words or talk for client? * Yes No Do family members anticipate or guess client’s needs by communicating? * Yes No Makes change or handles money: * Yes No Gets lost in conversations or complicated instructions: * Yes No Yes, The information is correct to the best of my knowledge. Privacy Policy * Signature of Patient/Legal Guardian * Order Number Child Intake Form Date of Evaluation: * Client First Name: * HIPPA Required Field. Client Last Name: * HIPPA Required Field. Date of Birth: * Referral Source: Reason for Referral: Email * HIPPA Required Field. Guardian/Caregiver Name: * Relationship to Child: * Home Phone: * Mobile Phone: PHYSICIAN INFORMATION Physician: Physician Phone: Physician Address: HEALTH / MEDICAL HISTORY Is your child in good health? * Yes No If not, please describe medical issues: Has your child been hospitalized? * Yes No If so, when and why: Does your child have a diagnosis? * Yes No If so, explain: Vision: * Normal Impaired Wears Glasses Contacts Hearing: * Normal Impaired Hearing Aid Cochlear Implant Has your child suffered from ear infections * Yes No If so, how many and at what age? Is Child: * Verbal Non-Verbal If child is non-verbal what is the primary mode of communication? Does child have feeding difficulties? * Yes No If so, please describe: Does child have difficulty swallowing (i.e. g-tube, ng-tube)? * Yes No If so, please explain: Does child have allergies? * Yes No If so, explain: List all medications child has taken in the past or is currently taking (dosage and type): Does child employ specialized equipment at home? * (i.e. standers, bathing/toilet chairs, wheelchairs, strollers, feeding chairs, adaptive equipment, feeding utensils, etc.)? Has your child ever had speech/occupational/physical therapy in the past? * Yes No What goals would you like your child to achieve during physical/speech/occupational therapy? DEVELOPMENTAL HISTORY Did your child exhibit any of the following behaviors during the first few years of life to a noticeable degree? Did not enjoy cuddling Was not calmed by being held or stroked Feeding difficulties Did your child fail to gain weight or grow normally? * Check only that applies and explain if possible. What ages did the following occur: Stood alone: Sat alone: Began to babble: Begin combining words: Walked unaided: Dressed and undressed self: Crawled Fed self with spoon: Produced first word: Taken off bottle: Taken off pacifier: Toilet Trained: FAMILY HISTORY Mother’s name: Father’s name: Mother's age: Father's age: Siblings: Name, Age, Gender Is there a family history of developmental delays, speech problems, hearing loss, or learning problems? * BIRTH HISTORY What was the duration of the pregnancy? Did you experience any of the following during pregnancy? * Infections Toxemia Surgeries Alcohol consumption Smoking Other None Other Did you take any medications during pregnancy? * Yes No If yes, please list: What type of delivery? C-Section Vaginal Were there any complications during pregnancy? What was your child’s birth weight? Were there complications during delivery? Select any that apply: Forceps Cord around neck Hemorrhage RH incompatibility Was your baby blue at birth? Did your baby have breathing problems upon delivery? * Yes No If yes, please describe: Was your baby in an incubator? Yes No Number of days: Was your baby in the NICU? Yes No Number of days: HOME/ PLAY/ SOCIAL BEHAVIORS All children exhibit, to some degree, the kinds of behaviors listed below. Please check those that you believe your child exhibits to an excessive or exaggerated degree to compared to other children of similar ages. Hyperactivity Does not learn from experience Impulsivity Head banging Tantrums Drooling Low frustration tolerance Eating inedible objects Reduced attention span Poor memory Sloppy eating habits Interrupts frequently Nightmares Does not listen when spoken to Whines frequently Sleep disturbances Destructive Reduced attention to danger Staring episodes Unusual fears (playground equipment, Accidents (falls, bumps into things), crowds, noises Repetitive movements (hand waving, rocking, spinning) What are your child’s favorite toys? What types of play activities does your child enjoy most? What toys/activities does your child dislike the most? What activities do you enjoy doing with your child? Does your child play with other children? * EDUCATIONAL HISTORY School your child is attending: * Grade: * What feedback have you received about your child’s school performance? *
