Forms

Name: Now We're Talking Pediatric Therapy
Telephone: (919) 359-1323
Price range: $$

Fill Out Your Paperwork Here

Now We're Talking Intake Forms

1Welcome

2Intake

3Medical

4Developmental

5Additional

6Consent

We are so happy that you have chosen us to be a part of your child’s journey to grow and develop!

In order for us to get started with the speech and language or occupational therapy process (evaluation and treatment), we require the following information and paperwork to be completed and submitted to us.

A copy of the child’s insurance card (front and back).
The following forms listed are to be filled out electronically and submitted for our records:

Client Intake Form
Consent to Treat in Daycare (if applicable)
Signature Authorization Page
Authorization to Release and Receive Information
Developmental/Medical History

Completely read and keep the following forms for your records

Financial Policy Statement
Financial Policy Statement (Español)
Notice of Privacy Practices- HIPPA
Policies and Procedures
Sick Policy
Authorization for Release and Receipt of Patient Information

Para descargar el formulario de la versión en español, haga clic aquí.

We look forward to working with your child and your family!

If you have any questions, concerns, comments please call (919) 359-1323 or email us at info@NowWereTalkingPT.com

CLIENT INTAKE FORM

This form provides your demographics for office keeping.

Child's Name(Required)

First Last

Today's Date(Required)

MM slash DD slash YYYY

Please, tell us why you're here...(Required)

You may select as many as you need to.

Speech Therapy

Occupational Therapy

Physical Therapy

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Month

Day

Year

Sex(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Cell Phone(Required)

Work Phone

Email(Required)

Enter Email Confirm Email

Add a Parent or Guardian?(Required)

Yes

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Cell Phone(Required)

Work Phone

Email(Required)

Enter Email Confirm Email

Pediatrician Practice(Required)

Pediatrician Office Phone Number

Office Fax

Primary Diagnosis / Medical Concern(Required)

Primary Insurance Company(Required)

Plan

Subscriber Number(Required)

2 Digit Number Next to Patients Name

Please enter a number from 00 to 99.

Do You Have Secondary Insurance(Required)

Yes

How would you like your invoice sent to you?(Required)

E-mailed

Mailed

N/A

Secondary Insurance Company(Required)

Secondary Plan

Secondary Plan Subscriber Number(Required)

Secondary Plans 2 Digit Number Next to Patients Name

Please enter a number from 00 to 99.

Place of Therapy(Required)

Please choose one

Name & Address of Daycare

Additional Details?

If you have any additional comments on therapy location please add them below.

Medical Records

Date(Required)

MM slash DD slash YYYY

Person Completing Form(Required)

First Last

Child's Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Age(Required)

Sex(Required)

Parent/Guardian:(Required)

First Last

Reason for Referral(Required)

Others Living in the House

Relationship

Age

History of Delays

Others Living in the House 1

Relationship 1

Age 1

History of Delays 1

Others Living in the House 2

Relationship 2

Age 2

History of Delays 2

Others Living in the House 3

Relationship 3

Age 3

History of Delays 3

Others Living in the House 4

Relationship 4

Age 4

History of Delays 4

Prenatal and Birth History

Please describe the mother's general health during the pregnancy of this child (illnesses, accidents, medications, complications, etc.)

Length of pregnancy?(Required)

Term(Required)

Full Term

Premature

Describe any unusual conditions at or immediately after birth

APGAR Score

Birth Weight

Hospital Stay

How Long?

Medical History

DEVELOPMENTAL/MEDICAL HISTORY

General Information

This form provides us with helpful information as part of our evaluation.

Any Medical Diagnosis?

Check all the Apply(Required)

Allergies

Ear Infections

Asthma

Pneumonia

Frequent Colds

Influenza

RSV

Croup

Headaches

Seizures

Tonsillitis

Draining Ear

None

Date of Last Hearing Test

Month

Day

Year

List Surgeries/Hospitalizations

Is your child currently taking any medications?

Developmental History

Provide the approximate age at which your child began to do the following (numbers only, no text):

Speech(Required)

(Babble, say 1st words, combine words)

Fine Motor(Required)

(color, write, cut, feed/dress self)

Gross Motor(Required)

(rolling, crawling, walking)

How does your child usually communicate?(Required)

Vocalizations

Eye Gaze

Voice Output Communication Device

Words

Gesture System

Object Communication System

Picture Communication Boards

Facial Expressions

Sign Language

Check ALL means of communications used by your child

Briefly Describe How and When They are Used(Required)

Describe your child's social/emotional skills(Required)

Relates well to other children

Prefers to be alone

Aggressive

Lacks Confidence

Active

Easily frustrated

Fearful of new situations

Immature

Shy

Poor judgement regarding personal safety

Check ALL that apply

Briefly Describe Your Selections(Required)

Additional History and Background

Primary Language Spoken at Home(Required)

Please list all the languages your child can speak and understand.

With whom does your child spend most of their time?(Required)

Does your child CURRENTLY receive any of the following services?(Required)

Early Intervention

Occupational Therapy

Speech-Language

Public School Services

Physical Therapy

Visual Impaired Services

None

Please indicate where and within whom...(Required)

Have any other specialists seen your child in the PAST?(Required)

e.g., speech-language pathologist, occupations therapist, physical therapist, physicians, psychologists, special education teachers, etc...?

Please describe your concerns and what your goals for your child are(Required)

Consent and Authorizations

Parent/Guardian Name(Required)

First Last

Child's Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

CONSENT TO TREAT IN DAYCARE/PRESCHOOL FACILITY

This form is necessary if your child is being seen in a daycare or preschool setting.

Daycare or Preschool Name(Required)

Address of Daycare or Preschool

Daycare / Preschool Phone Number

Best Days/Times to be Seen

Notes or Directions to Follow

CONSENT TO TREAT IN DAYCARE/PRESCHOOL FACILITY(Required)

In signing below, I give permission for "Now We're Talking" Pediatric Therapy, Inc. to provide speech and language/occupational therapy/physical therapy to my child, in his/her Daycare facility. I also give permission for my child to be seen within the classroom or to be taken to a separate area in order to target specific therapeutic goals.

CONSENT TO SHARE THERAPY GOALS WITH CLASSROOM TEACHERS(Required)

In signing below, I give permission for "Now We're Talking" Pediatric Therapy, Inc. therapist to discuss therapeutic techniques and therapy goals regarding my child with his/her classroom teachers at the daycare or preschool listed above. In doing this his/her classroom teachers can reinforce therapy goals within the classroom environment throughout the day.

LIABILITY WAIVER(Required)

I Agree

I (parent's name), the parent of (child’s name), agree to follow the above protocol during our scheduled therapy session. I understand that “Now We’re Talking” Pediatric Therapy, Inc. is taking all necessary health precautions and is not to be held responsible if anyone in my family becomes ill.

AUTHORIZATION PAGE

This form gives us permission to bill your insurance, permission to evaluate and treat, permission to video or audio tape for therapeutic purposes (optional), permission for use of photos for social media (optional) and states that you have read the financial policies and procedures and received our HIPAA statement.

FINANCIAL POLICY STATEMENT(Required)

I have read “Now We’re Talking” Pediatric Therapy, Inc (NWT) financial policy statement and I UNDERSTAND MY RESPONSIBILITIES FOR THE PAYMENT OF MY ACCOUNT.

Financial Policy Statement

Financial Policy Statement (Español)

CONSENT FOR CARE AND TREATMENT(Required)

By my signature below, I do hereby agree and give my consent for NWT to furnish necessary evaluations and treatment.

BENEFIT ASSIGNMENT / RELEASE OF INFORMATION(Required)

I, hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicaid, private insurance and third party payers to NWT as it may be necessary for billing and collection purposes. A photocopy of this assignment is to be considered as valid as the original.

INFORMATION PRIVACY STATEMENT (HIPAA)(Required)

NWT will use and disclose you(r) child’s personal health information to treat them, to receive payment for the care we provide, and for other health care operations. Health care operations generally include those activities we perform to improve the quality of care. By signing below, I acknowledge receipt and review of NWT’s Notice of Privacy Practices.

Information Privacy Statement - HIPAA

POLICIES AND PROCEDURES(Required)

I have received and familiarized myself with NWT Policies and Procedures and agree to the statements regarding our treatment session times, cancellation and no show policy, infection control procedures, inclement weather policy, and patient rights and responsibilities.

Policies and Procedures

AUTHORIZATION TO PHOTOGRAPH FOR ART PROJECTS, NWT WEBSITE OR FACEBOOK:

I agree

(Not required)

AUTHORIZATION TO VIDEO/AUDIO FOR DIAGNOSTIC/THERAPUETIC PURPOSES:

I Agree

(Not required)

AUTHORIZATION OF RELEASE/RECEIPT OF PATIENT INFORMATION

Please list anyone with whom we can receive and release information about your child. For example, your pediatrician, CDSA (Children’s Developmental Services Agency or early intervention), public school, other therapists and/or specialist physicians. If someone is not listed on this form we cannot share or receive information with them.

Authorization of Release/Receipt of Patient Information(Required)

I hereby authorize “Now We’re Talking” Pediatric Therapy, Inc to release and receive information in my patient record to:

Examples may include Pediatrician Practice Name and/or Pediatrician

Examples may include teachers, counselors, extended family etc...

This request shall be valid for the duration of treatment unless previously revoked or otherwise indicated (specify the number of days or months):

Reason for Release

Other Information

Consent(Required)

I understand that by signing this form, that I hereby agree and authorize the release of patient information to the above-named person or organization. I have the right to revoke this authorization, in writing, at any time by sending such a written notification to “Now We’re Talking” Pediatric Therapy, Inc office address. However, I understand that my revocation will not be effective to the extent that action based on this consent has been taken.

Relationship(Required)

Phone

This field is for validation purposes and should be left unchanged.