Bicounty_child

CHILD INTAKE FORM
*Please take some time to fill out the information below. We ask that you return the information digitally, so that we have the information before the evaluation appointment time. Thank You.
Patient Information:
Patient Name
DOB

MonthDayYear
Date
Phone Number
Patient Address
Email
example@example.com
Primary Care Provider
Primary Care Phone
Primary Care Fax
Please enter a valid phone number.
Emergency Contact Name
Phone Number
Relation
Insurance Information:
Patient Name
Insurance
Member ID
Subscriber Name
Phone Number For Benefits
Reason For Referral:

Select All That Apply
Academic ConcernsSensory Processing IrregularitiesFine/Gross Motor DelaySocial Skills DelayAttention DeficitsFeedingDevelopmental DelayBehavioral ConcernsSpeech ConcernsLanguage ConcernsProcessing Of InformationFluency ConcernsVoice Concerns
What are your concerns with your child today?
For example; How does your child talk when they talk with you, do they use their own way of speaking or will your child use whole sentences or phrases? Can you give an example?
Family Background:
Parent/Guardian
Child Lives With
Sibling(s) Name(s) And Age(s)
Languages Spoken In The Home
Discipline:

AdequatePermissiveStrictInconsistent
Prenatal Health:
Weeks of Gestation
Birth Weight
Length
If Preemie APGAR Scores
Complications
Developmental Milestones:
Age: Crawled (crawls on all 4’s/quadruped)
How long did they crawl?
Did they use quadruped with correct hand and leg placement?
Walked
Babbled
First words
Aversions: (Select All That Apply)

TouchSmellSoundsTastesFace WashingTeeth BrushingFood
Other: If aversive reaction, how do they respond and are they able to self soothe?
Education:

Select All That Apply
SchoolPreschoolDaycareHome
Other
Name of School
Has your child been evaluated by the school district?

YesNo
If yes, please bring a copy to the initial evaluation session.
Does your child currently have an:

IEPIFSP
Other
Does your child currently have a diagnosis?

YesNo
If yes please list the diagnosis
Behavioral Observations:

Select All That Apply
Auditory/Visually Alert and AttentiveAuditory/Visually Alert Yet InattentivePoor Eye ContactAppropriate Use of Eye ContactAge-Appropriate Attention SpanShort Attention SpanAppropriate Attending and RespondingWell-BehavedInconsistent Attending and Responding BehaviorsCooperativeUncooperativeFriendlyDistractedRestricted AffectEasily Separated from ParentsEasily FrustratedSociableImmatureInteractiveNon-InteractiveHyperactiveImpulsiveSeparation AnxietyShyEmotional
Other
Sensory Considerations:

Select All That Apply
Type a question

Enjoys JumpingVery ActiveWalks On ToesEnjoys Throwing ThemselvesBiting, Themselves or OthersSpinningEnjoys Throwing ObjectsChewing On Objects
Does your child have an aversion to a specific sound or texture? If yes, please explain.
Feeding/Oral Motor:
Breastfeeding with proper latching?

YesNo
When did they finish breastfeeding?
Bottle-feeding with adequate suck?

YesNo
When did they finish bottle feeding?
Uses Pacifier?

YesNo
Bites/Chews Straw?

YesNo
Tolerates Food Textures?

VarietyLimited
Uses Utensils to Feed Self?

SpoonForkKnifeAssisted FeedingFinger Feeds
Drinks From:

BottleSippy CupStraw CupRegular Cup
Chokes when eating or drinking?

YesNo
If yes, how often?
Current Form(s) Of Communication:

Select All That Apply
GesturesPhysical DirectingVocalizationsBabblingJargonEcholaliaSentencesWord UtterancesOccasional PhrasesAugmentative2-Word PhrasesCode SwitchingDevice
Other
Vision:

Select All That Apply
Appears WNLVisually ImpairedWears GlassesWears ContactsNystagmusStrabismusTracks HorizontallyTracks VerticallySmooth/JerkyConvergence
Other
Hearing:

Select All That Apply
Appears WNLApparent Hearing DeficitsWears Hearing Aide (s)Startles EasilySign LanguageAuditory ProcessingAAC
Device
History of Ear Infections?

YesNo
If yes, how many ear infections have they had in a month?
On Antibiotics?

YesNo
Change In Antibiotics?

YesNo
Did the infection clear up with the medicine or did it recur?

Cleared upRecur
Gross motor:

Select All That Apply
Type a question

Independent MobileDependentWalkerCrutchesOrthoticsCane
Other
Requires assistance with:

Select All That Apply
Does Not Require AssistanceShirtPantsSocksShoesButtonsZippersSnapsLacing/TyingWashing Hands/FaceWashing Body/HairBrushing TeethBrushing Hair
Other
Toileting Status:

Select All That Apply
Independent/Potty trainedTrainingWears diapers
Comments
Consent to Treat:
I, _______________ the parent/guardian
of __________give consent for all evaluation(s) and client centered treatment(s
The treatment has been recommended by (Doctors Name)
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I certify that I have received a copy of Bi-County Therapy's Notice of Privacy Practices. The notice describes the types of used and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Bi-County Therapy's operations. The notice also describes my rights and Bi-County Therapy's obligation to respect my protected health information. The Notice of Privacy Practices is also posted at the front desk of the office. Bi-County Therapy can change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Name
Signature

Clear
Date

MonthDayYear
Date
Photo Consent Form
In connection with the medical services, I am receiving from my therapists at Bi-County Therapy, I consent that photographs may be taken of me or parts of my body, under the following checked conditions:

The photographs may be taken only with the consent of my therapist and under such conditions and at such times as may be approved by him/her.

The photographs shall be taken by my therapist or a photographer approved by my therapist/Bi-County.

The photographs shall be used for medical records, and if in the judgement of my therapist, Bi-County, medical research, education, or social media will be benefitted by their use, such photographs and information relating to my case may be published and republished, either separately or in connection with each other, in professional journals or used for any other purpose that may be deemed proper in the interests of medical education, social media, or research; provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name.

The photographs may be modified or retouched in any way that my therapist or Bi-County may consider desirable.

The photographs shall be used as part of my therapist's office display of patients, visible to office visitors, for as long as my therapist and Bi-County wishes to keep them posted, subject to my revocation in writing.
Guardians Name
Date

MonthDayYear
Date
Virtual Consent
During this challenging time and in an effort to continue proper care to the patient, Bi-County Therapy is offering several ways to maintain your therapy schedule. You are now able to work with a therapist in person at the clinic, or you can take advantage of our new "Teletherapy" sessions, which are conducted privately through video conferencing. If you want to utilize Teletherapy, Bi-County Therapy requires your written consent to conduct teletherapy with you, your family member, or your child. At Bi-County, we are taking all measures to make sure your Teletherapy session complies with privacy regulations and provides a positive experience. By consenting, you agree that you understand there is a very low-level risk with regard to your teletherapy session being exposed to someone else. Therapists will take every precaution to conduct your session in private, but you must also do your part to maintain privacy cancellations.

Your therapist will prepare you prior to each Teletherapy session since parental involvement is an important element. In essence, you will become the 'hands' of the therapist from the convenience and safety of your home.

If you have any questions along the way, please do not hesitate to contact your therapist directly. The office can also assist you please call (954) 312-3449 ext: 200 for questions or ext. 204 for appointments.

We sincerely hope we are providing a positive, safe and healthy alternative for your loved one's continued care.
Name
Signature

Clear
Date

MonthDayYear
Date
Attendance Policy
Name of Patient
We understand that there are legitimate reasons for having to cancel an appointment, however, we also ask you show consideration by calling well in advance if you are unable to keep an appointment. If a situation occurs needing cancellation, please call the office at 954-312-3449 Ext 204 with the cancellation request and the reason for the cancellation. Consistent attendance is required in order to make progress in therapy. To that end, Bi-County Therapy is updating the attendance policy.

Cancelations MUST be made 24 hours in advance with the front desk. Therapists will no longer be accepting via text or phone call. Late cancellations will incur a $25 no show fee to be paid via credit card, debit card or zelle.

If you are unable to attend in person therapy, it may be possible to do a teletherapy visit for virtual therapy when appropriate.
Clients are allowed no more than 3 cancellations within a month before being placed on an "on call list." The "on call list" will be used when a therapist has an opening to be filled. You will receive a call asking if you would like to accept a session on a particular day and at a particular time with an available therapist. You can either accept or decline the appointment at that time. You can also elect to join the "on call list" if you are struggling to make weekly appointments consistently.

If you are going to be out of town or have some kind of "emergency" situation that will be more than the 3-session limit, you can request a 2 week "leave of absence" so that you will not lose your spot. After the 2 weeks, if you are not able to attend either in person or virtually you will be placed on the"on call" list.

If you accept an "on call" appointment and do not attend at the new appointment time for that session you will be charged a $25 no show fee. If you do not attend an "on call" appointment 2 times after confirming, you will be removed from the "on call" list and discharged due to lack of attendance.
I, _____________
agree to reimburse Bi-County Therapy Inc. for the fees incurred as stated in the attendance policy above. If I do not settle my bill and I am sent to collections, I agree to pay the fees of any collection agency, which will be added to the account at the time it is placed with an agency for collection and all reasonable costs and expenses, including reasonable attorneys' fees, incurred in such collection efforts.
Signature Of Payor

Clear
Date

MonthDayYear
Date
No – Show Policy
Patient Name
We understand that there are legitimate reasons for having to cancel an appointment. We ask you to show consideration by calling well in advance if you are unable to keep an appointment. We ask that you call the office, text your therapist, or email your therapist with the cancellation request and the reason for the cancellation. We would like to have the option to offer that appointment to another patient who needs to see the therapist.

Please let this notice serve to notify you that if you fail to give US 24 hours notice of cancellation, there will be a $25.00 cancellation billed to your account that cannot be filed to your insurance. This fee will have to be paid prior to your next therapy appointment.

I understand the No-Show Policy for Bi-County Therapy and agree to comply with the 24-hour rule.
Guardian's Name
Guardian's Signature

Clear
Date

MonthDayYear
Date
Please complete all fields. You may cancel this authorization at any time by contacting US 312-3449 EXT 203. This authorization will remain in effect until cancelled.
Credit Card Information
Card Type

MasterCardVisaDiscover
First 4 digits of card
Second 8 digits
Last 4 digits
Expiration Date (MM/YY)
CVV
I, __________________
Cardholder Name *(as shown on card)
authorize Bi-County SLP to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account WE WILL NOTIFY YOU BEFORE WE CHARGE YOUR CARD.
Signature

Clear
Zelle
Date

MonthDayYear
Date
We are excited to now accept Zelle as a more convenient and secure form of payment. Please make payments to payment@bicountyslp.com and recipients name as BiCounty please add your child's first and last name and what the payment is for in the proper section on Zelle.

I attest that the information in this document is true and accurate.
Name Of Person Filling Out This Form
Relation To Patient
Date

MonthDayYear
Date
Should be Empty:

CHILD INTAKE FORM

Patient Information:

Insurance Information:

Reason For Referral:

What are your concerns with your child today?

Family Background:

Prenatal Health:

Developmental Milestones:

Education:

Behavioral Observations:

Sensory Considerations:

Feeding/Oral Motor:

Current Form(s) Of Communication:

Vision:

Hearing:

Gross motor:

Requires assistance with:

Toileting Status:

Consent to Treat:

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Photo Consent Form

Virtual Consent

Attendance Policy

No – Show Policy

Zelle