lifeskills_SKILLS _Group

S.K.I.L.L.S. GROUP REGISTRATION
Todays Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Parent/Guardian Name(s)
Primary Address

Address

Street Address Line 2

CityState / Province

Zip
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Which S.K.I.L.L.S. Group are you registering for:
Who referred you to the group:

Rows	Yes	No
Does your child have any medical or educational diagnoses?
Does your child have an IEP?
Does your child receive speech or occupational therapy outside of school?
Does your child have any allergies?

Please explain any “yes” answers

0/150
PATIENT INFORMATION
Name of Person Financially Responsible
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Social Security
Phone Number
Format: (000) 000-0000.
Email address
example@example.com
POLICIES/CONSENT/RELEASES
The Center for LifeSkills and Stefanie J. Peck, M.A. CCC-SLP require payment at time of services for office visits. Payments must be made by cash, check or credit
I understand that I am ultimately responsible for paying my entire bill should any third-party payor deny payments for any reason. (initial here)
I understand that payment is required at the time of service, by cash, check or credit, unless alternate arrangements are made.(initial here)
All health information is kept safe, as required by law. I acknowledge that I have read The Center for LifeSkills/Stefanie Peck Notice of Privacy Practices, available on our web site. (initial here)
I consent to treatment for my child(ren) by The Center for LifeSkills, LLC, Stefanie Peck, MA CCC-SLP or other therapists/student clinicians associated with them. (initial here)
I give permission for the therapist to accompany my child to the bathroom if necessary.
Please state in the field below if you give permission or do not give permission for the following situations. Media will not be shared with any third parties. This release will remain active until I notify The Center for LifeSkills/Stefanie Peck:
MEDIA RELEASE

Please choose the appropriate drop down answer for the individual media releases
My child's therapist can use their phone to take pictures or videos to share with only me or other therapists at this facility.
My child can participate in photos and videos for media/marketing purposes for The Center for LifeSkills/Stefanie Peck;
On Facebook/Instagram
On our website (www.center4lifeskills.com)
On flyers or other marketing materials
Parent/Guardian's Name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Childs Name and DOB
Parent/Guardian Signature
Should be Empty:

S.K.I.L.L.S. GROUP REGISTRATION

PATIENT INFORMATION

POLICIES/CONSENT/RELEASES

MEDIA RELEASE