letstalktherapy

Client Intake Form
Child’s name:
Middle Initial
Last
MaleFemale
Child Care Center
Arrival Time
Leave Time
Date of Birth

MonthDayYear
Date
Medicaid #
Part

AB
Insurance Company and Policy#: Primary Care Physician:
Insurance Company and Policy #
Primary Care Physician
*****PLEASE CHECK WHICH PARENT IS THE INSURANCE SUBSCRIBER******

MotherFather
Mother's Name
Address
Phone
EMail
example@example.com
Father's Name
Address
Phone
EMail
example@example.com
List the names and ages of siblings
BIRTH HISTORY
Length of Pregnancy
Complications:

YesNo
If yes please explain
Birth Weight
Length of Hospital Stay
DEVELOPMENTAL HISTORY

At what age did your child:
Sit Alone:
Crawl:
Walk:
Babble:
Say First Word:
MEDICAL HISTORY
Date of last Well Child Checkup

MonthDayYear
Date
Medical Diagnosis (if there Is one)
Does your child have any allergies?

YesNo
If yes, please list allergies:
Is your child currently on any medications?

YesNo
If yes, please list medications:
Has your child had any serious injuries or ever been hospitalized?

YesNo
If yes, at what age and how many:
Has your child ever had an ear infection?

YesNo
If yes what age and how many
Has the child’s hearing ever been tested?

YesNo
When?
Results:
Does the child have any family members with a history of developmental delays, learning problems,hyperactivity, hearing or speech difficulties?

YesNo
Explain:
Please list any concerns you have about your child’s speech and language:
Permission Form
SELECT SERVICE:

Speech TherapyOccupational TherapyPhysical Therapy
I, _________________________________________,
the parent of________________________
give permission for an evaluation to be conducted with my child to determine if therapy is needed. I also give my permission for treatment, if deemed necessary by test results and the child’s primary care physician.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
MEDICAID RELEASE AND ASSIGNMENT
I request that authorized Medicaid Payments be made to Let's Talk Speech Pathology Services, LLC, for any services furnished by them to my child.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
INSURANCE RELEASE AND ASSIGNMENT
I certify that my child is covered by insurance with ______________________
and assigned directly to Let’s Talk Speech Pathology Services, LLC, all insurance benefits, if any, otherwise payable to me for services, rendered. I understand that I am financially responsible for aU charges whether or not paid by insurance. I hereby authorize Let’s Talk Speech Pathology Services, LLC and/or Central Arkansas Therapy to release all information necessary to secure payments of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
PRIVACY POLICY
have received a copy of the privacy policy. The privacy policy can be obtained from our website at www.letstalkar.com/parent-resources.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Client Intake Form

BIRTH HISTORY

DEVELOPMENTAL HISTORY

MEDICAL HISTORY

Permission Form

PRIVACY POLICY