lifeskills_Registration_and

Today's Date

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Age
PARENT/GUARDIAN 1
Name
Email
example@example.com
Phone Number
Address

Primary Address

Street Address Line 2

CityState / Province

Zip
I am a legal guardian

YesNo
If no please explain
PARENT/GUARDIAN 2
Name
Email
example@example.com
Phone Number
Address

Primary Address if different than above

Street Address Line 2

CityState / Province

Zip
I am a legal guardian

YesNo
If no please explain
Referred by:

Insurance CompanyInternetCurrent ClientOther
If current client, please name
If other, please list
Pediatrician's Name and Phone Number
Specialist's Name and Phone Number
Current Diagnosis (if any)
PAYMENT INFORMATION
Name of Person Financially Responsible
Date of Birth

MonthDayYear
Date
Address
Social Security Number (required for all families)*
INSURANCE INFORMATION
I will not be using insuranceI will be using Autism Scholarship/JPSN FundsI will be using both insurance and Autism Scholarship/JPSN Funds
Insurance Company
Employer's Name
Policy Holder's Name
Address if different from above
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Social Security Number
Policy Number
Group Number
SECONDARY INSURANCE INFORMATION

(If applicable)
Insurance Company
Employers Name
Policy Holder's Name
Policy Holder's Address (if different from above):
Street
City
Zip
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Holder's Social Security Number
Policy Number
Group Number
POLICIES

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. In some instances, an invoice will be sent. Invoices are due within 30 days of being sent. There will be a $25 charge for balances that are 30+ days past due. (initial here)*
I understand my insurance benefits, including my deductible, co-pay, co-insurance, and session/visit limits. I agree to keep track of the number of sessions attended and understand that I am responsible for paying for any sessions that my insurance does not cover. My insurance company is ultimately responsible for how claims are processed. (initial here)*
HIPAA
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. (initial here)*
CANCELLATIONS

I agree to notify my therapist of any vacations/scheduled absences, so that make-up sessions can be scheduled. Advance notice is appreciated, as we can use those time slots for other make-up sessions or meetings.
I understand that there will be a $45 charge if a session is missed without notification. I must notify my therapist about a cancellation at least 8 hours in advance of the scheduled appointment to avoid the $45 charge. I understand that this fee cannot be paid for by a third-party payor and will be my responsibility. (initial here)*
I understand that my child must be present at 75% of his/her regularly scheduled sessions, in any rolling 3-month period. If the attendance percentage drops below 75%, the regularly scheduled time slot may be forfeited. (initial here)*
CONSENT TO TREAT
I have read the above policies and agree to the terms. I consent to treatment for my child by The Center for LifeSkills, LLC, Stefanie Peck, MA CCC-SLP or other therapists/student clinicians associated with them. (initial here)*
Please state in the field below if you give permission or do not give permission for the therapist to accompany your child to the bathroom if necessary. (initial here)*
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 or Instagram.*
On our website (www.center4lifeskills.com)*
On flyers or other marketing materials that might be posted online or passed out at schools, resource fairs, etc.*
Parent/Guardian's Name
Parent/Guardian Signature

Clear
Date Signed:

MonthDayYear
Date
Should be Empty:

PARENT/GUARDIAN 1

PARENT/GUARDIAN 2

PAYMENT INFORMATION

INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

POLICIES

HIPAA

CANCELLATIONS

CONSENT TO TREAT

MEDIA RELEASE