Office Use Only: Received by ______ Date ______
Patient Reservation Form Completed ______
Client Intake Questionnaire
I am interested in the following services for my child: (check all that apply)
Speech and Language Services:
Occupational Therapy Services:
ABA-Behavioral Services:
_______ Evaluation
_______ Evaluation
_______ Evaluation
_______ Therapy Services
_______ Therapy Services
_______ Therapy Services
Child’s Full Name ________________________________________________________
DOB ______________________ Gender M or F (Circle One) Age________________
Child lives with: __________________________________________________________
Mother’s Name___________________________________________________________
Address ________________________________________________________________
City _______________________________ State ___________ Zip ________________
Home Phone _________________ Work _________________ Cell _________________
Email _____________________________
Occupation__________________________
Father’s Name____________________________________________________________
Address _____________________________________________ Zip ________________
Home Phone _________________ Work _________________ Cell _________________
Email _____________________________
Siblings? ___yes ___no
Occupation _________________________
Ages? __________________________________________
School/Daycare __________________________________________________________
Pediatrician _________________________________ Phone: _____________________
Has your child received any diagnosis (Please specify): __________________________
List secondary (Axis II) diagnoses: __________________________________________
Who was the diagnosing physician? _________________________Phone:___________
Please list any medical conditions: ___________________________________________
________________________________________________________________________
Please list any medications and dosage that your child is taking: ____________________
________________________________________________________________________
Prescribing physician:___________________________ Phone: ____________________
Does your child have allergies? Please list: ____________________________________
________________________________________________________________________
Does your child have funding through: ____Early Steps ____Medicaid
____TriCare
Private Insurance Carrier: __________________________________________________
Policy Number: ___________________________ Group Number: _________________
Does your child currently receive any of the following interventions?
____Speech therapy
Provider: __________________________________
____Occupational therapy
Provider: __________________________________
____Applied Behavior Analysis
Provider: __________________________________
____Developmental Services
Provider: __________________________________
____Dietary
Specify: __________________________________
____Biomedical
Provider: __________________________________
Specify: __________________________________
Other: __________________________________________________________________
Pregnancy/Birth History
Did you carry your child full term? _______
Birth weight = ___________
Did you have a natural birth? ______
Or did you have a C-section? ________
Any complications during pregnancy and/or the birthing process? ___________________
________________________________________________________________________
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Were you in good health throughout your pregnancy? ____________________________
Were you taking any medications during your pregnancy? _________________________
Did your child require any special hospital care after birth? ________________________
Were any follow-up doctor visits required? _____________________________________
Does your child have any history of the following (Check any that apply):
____ear infections
____strep
____ear tubes
____skin problems/eczema
____dark circles under eyes
____loose stools
____constipation
____difficulty sleeping
____food allergies
Comments on checked items: _______________________________________________
________________________________________________________________________
________________________________________________________________________
Did your child have difficulty with any of the following:
____sucking
____chewing
____swallowing
____changing to solid food
Is your child a picky eater? _______ If yes, what types of foods does s/he prefer?
__________________________________________________________________
Does your child feed him/herself? ___________
Does your child exhibit feeding problems (overstuffing food, texture aversion, gagging)?
________________________________________________________________________
Communication (Please check each skill that your child CAN do independently):
At what age did your child do the following:
Babble
____________
Imitate sounds ____________
Combine words ____________
Understand speech_____________
Say first word(s) _____________
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Does your child:
____point to an item of interest
____label everyday objects
____respond when name is called
____use phrases appropriately
____greet others (hi/bye-bye)
____ask for help
____follow instructions
____bring an item to you for help
____combine two words (Mommy juice, go car)
____ask questions (what/where/who)
____use other’s name to get attention
____comment to another (Look, it’s a ______!)
____answer by saying “yes” or “no”
____understand what s/he is being told
Does your child echo or repeat words immediately after hearing them or at a later time?
_________________________
Does your child repeat phrases from a favorite video/song/movie? ________________
Is your child’s speech easily understood by others? ____________________________
How many words does your child speak? ____________________________________
Does your child understand what you say to him/her? ___________________________
Did your child ever experience a loss or regression in his/her speech? ______________
If yes, at what age did you notice this? _______________________________________
Sensorimotor History:
Dislike being held or cuddled?
Yes
No
Constantly touch objects/people or intrude in others personal space?
Yes
No
Seem easily irritated or enraged?
Yes
No
Pinch, bite or otherwise hurt him/herself or others?
Yes
No
Frequently bumps or pushes others?
Yes
No
Doesn’t cry when seriously hurt/overreacts to small injuries?
Yes
No
Dislike/seeks out the feeling of fuzzy/furry clothing/textures?
Yes
No
Seem overly sensitive to certain food textures/tastes/smells?
Yes
No
Dislike having hair washed/ cut or nails cut?
Yes
No
Dislike/seeks out the feeling of sand, mud, and clay on hands/feet?
Yes
No
Seem unaware of food/liquid left on lips?
Yes
No
Like rough housing, jumping, crashing games?
Yes
No
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Prefer swings, slides, spinning rides, being held upside down?
Yes
No
Get carsick easily?
Yes
No
Get nauseous and/or vomit easily?
Yes
No
Have fear in space/or with feet off the ground (stairs, heights)?
Yes
No
Lose balance easily?
Yes
No
Walks on toes (not flat feet)?
Yes
No
Prefer to be sedentary (on computer/ TV) than play outside?
Yes
No
Have a diagnosed vision problem?
Yes
No
Have trouble copying words from the board?
Yes
No
Chew on non-food items (pencils, shirt, hair)?
Yes
No
Taste or smell objects when playing with them?
Yes
No
Fail to listen, or pay attention to what is said to him/her?
Yes
No
Like to play or make music at loud volumes?
Yes
No
Has difficulty if 2 or 3 directions are given at once?
Yes
No
Talk excessively/not wait for a turn?
Yes
No
Seem unorganized/lose possessions easily?
Yes
No
Slouch when sitting on floor/chair?
Yes
No
Seem generally weak compared to other kids?
Yes
No
Sit, stand or walk late?
Yes
No
Was creeping and crawling phase unusually prolonged?
Yes
No
Was creeping and crawling phase almost entirely omitted?
Yes
No
Yes
No
position?
Yes
No
Have poor handwriting?
Yes
No
carton, water bottle etc.)?
Yes
No
Able to ride a bike (tricycle, big wheel)?
Yes
No
Able to tie shoelaces?
Yes
No
Have difficulty with sequential tasks; dressing, buttoning,
zipping?
Have difficulty learning to hold a pencil or crayon in an adult like
Have trouble using both hands together easily (opening milk
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Social:
Does your child do any of the following (Check all that apply):
____prefer to play alone
____pretend play (talk on phone, feed animals)
____play with toys appropriately
____line toys in a row
____construct with blocks
____imitate the play of other children
____prefer to play a certain way
____show an interest in other children
____play back and forth games (peek-a-boo, tag, hide and seek)
Does your child notice/attempt to comfort when another child is upset or hurt? ________
Does your child have difficulty making/keeping friends? __________________________
Does your child have difficulty with winning/losing/competition? __________________
Behavior:
Does your child exhibit any of the following (Check any that apply):
____seem in his/her own world
____attached to unusual objects (stick, hair, string)
____resistant to change
____difficulty transitioning
____excessive tantrums
____aggression (hit, push, bite others)
____eats/chews on non-food items ____watches the same video repeatedly
____mood swings
____spins body or objects
____dislikes certain textures
____clumsy
____little or no sense of safety
____high pain tolerance
____can’t sit still (hyperactive)
____climbs/jumps on furniture frequently
____hurts self (bangs/hits head)
____seem to “space out” at times
____non-compliance
____property destruction
____lack of respect for authority
____poor frustration tolerance
Does your child have a history of behavior problems in school? ____________________
Is your child’s behavior different in certain settings or with certain people? ___________
________________________________________________________________________
Does your child become obsessive about one or several topics?
_______________________________________________________________________
Does anyone in your family have a history of a condition which affected his/her development,
ability to learn, or mental health? ____________________________________________
_______________________________________________________________________
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Please list your primary concerns regarding your child’s development:
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
4._____________________________________________________________________
Please list any community resources that your family is currently utilizing:
_______________________________________________________________________
Other important information:________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Dear Parents,
A copy of your child’s most recent evaluation by a Speech/Language Pathologist, Occupational
Therapist, and/or Behavior Analyst; MUST BE PROVIDED PRIOR TO RECEIVING
THERAPY SERVICES.
Please be advised that an evaluation is required prior to treatment, unless an acceptable and
recent (within 6 months) evaluation is provided. The fee for the evaluation is based on the time it
takes for the therapist to evaluate and develop a written report and treatment plan. PLEASE
NOTE: If you wish to bill your insurance company, a prescription from your pediatrician is
needed prior to setting up an appointment for an evaluation. Although a prescription is not
required by law, most insurance companies required it before processing or paying out the claim.
Please check appropriate statement below and circle any services needed for your child.
____ I want my child to receive an evaluation for the following service(s): Speech
OT
ABA
____ I will be submitting a recent evaluation from the following service(s): Speech
OT
ABA
I have read and fully understand the above statement.
___________________________________
Parent/Legal Guardian Signature
_______________________
Date
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CONSENT FOR TREATMENT
I hereby authorize Pinnacle Pediatric Therapy Group to evaluate and/or provide therapy to my
child.
__________________________________
Signature of Legal Guardian
________________________
Date
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Pinnacle Pediatric Therapy Group to obtain information from and release
information to the following individuals and organizations:
______________________________________________________________________
______________________________________________________________________
__________________________________
Parent/Guardian Signature
______________________
Date
ATTENDANCE AND SCHEDULING POLICY
1. I understand that a treatment session consists of 50 minutes of direct treatment. An additional
10 minutes is used for parent consultation, set-up, clean-up and transitions into and out of the
treatment. ________(initials)
2. I understand that in order to receive the maximum benefit from treatment, it is important for
treatment to occur at the treatment frequency determined between the therapist and family. I
understand that notification of vacation or family obligation is requested at least two weeks prior
to the expected absence, to facilitate rescheduling our appointment. I understand that we may
schedule make-up sessions for vacation times, if there are times available. _______(initials)
3. I understand that for sessions cancelled with less than 48 hours notice (unless the child
becomes ill in the morning); a cancellation fee of $50.00 will be charged and is billed directly to
me. I understand that if sessions are cancelled with more than 48 hours notice, I will not be
charged a cancellation fee; however, this clinic encourages scheduling a make up for these and
all other sessions in order to ensure optimal progress. _______(initials)
4. I understand that if we do not cancel and do not keep a scheduled appt {NO SHOW}, we will
be charged the full fee for the session. I also understand that three no shows will result in the
termination of our treatment slot. _______(initials)
8
5. I understand that if my child was not well enough to attend school on the day of his/her
appointment that I should not bring him/her to the scheduled therapy session that day. I also
understand that if my child attends therapy, and then comes down with an infectious illness or
condition such as strep throat, conjunctivitis, chicken pox, lice, etc. I should notify the clinic
immediately so that other children in the area that day can be notified. ________(initials)
PAYMENT POLICY
1. I understand that the clinic cannot wait for payment and that my co-payments or private
payment is due no later than 14 days from receipt of invoice. All checks are to be made payable
to Pinnacle Pediatric Therapy Group. Payment may be mailed or delivered to the office.
_______(initials)
2. lf my account becomes overdue by 30 days, I understand that Pinnacle Pediatric Therapy
Group will discontinue therapy until payment is made. _______(initials)
3. I understand that this clinic may bill my insurance companies directly at my request only when
all of the proper insurance information is on record in the office. It is my responsibility to
contact my insurance plan to find out exactly what is required for direct billing. _______(initials)
4. I understand that my amounts not covered by my insurance, including deductibles,
coinsurance, non-reimbursable items (such as reports, consultation, and travel) must be paid by
the due date or treatment will be discontinued. I also understand that submission of claims to the
insurance company does not guarantee payment and that I will be held responsible for all
amounts billed. _______(initials)
5. I understand that if a claim submitted directly by this clinic to my insurance company is not
paid within 60 days of submission, the balance becomes due immediately from me. The clinic
will assist in obtaining insurance coverage by writing reports and letters to insurance companies.
______(initials)
6. I understand the need to provide notification of outside meetings or consultations at least three
weeks in advance to allow the therapist(s) to prepare and to coordinate meeting dates and times. I
understand that if I want my therapist to attend an outside meeting (lEP, TEAM meeting, etc.) I
will be billed the hourly consult rate plus travel time to and from the appointment.
_______(initials)
7. I have read the above information and understand that, as a client, parent, or guardian, I am
ultimately responsible for payment of all services provided by Pinnacle Pediatric Therapy Group.
In the event that my insurance company or other source of payment decreases or discontinues
payment for services for any reason, I will be responsible for assuming payment for past, current,
and future services. ______(initials)
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TEACHING AND RESEARCH ACTIVITIES
1. I recognize that this clinic is a professional development site for Universities and professional
organizations. I give permission for therapy student interns to observe my child's therapy. I
understand I will be notified prior to each observation. ______(initials)
2. I give permission for photographs/videotapes to be taken of my child for educational
and professional development training purposes. ______(initials)
HIPAA CONSENT TO USE DISCLOSURE INFORMATION
FOR TREATMENT AND HEALTH CARE INFORMATION
Federal regulations from the Health Insurance Portability and Accountability Act
(HIPAA) allow us to use or disclose Protected Health Information (PHI) from your
records in order to provide treatment to you, and for other professional activities (known
as “health care operations”). Nevertheless, we ask your consent in order to make this
permission explicit. The Notice of Privacy Practices describes these disclosures in more
detail. You have the right to review the Notice of Privacy Practices before signing this
consent. We reserve the right to revise our Notice of Privacy Practices at any time. If we
do so, the revised Notice will be posted in our office. You may ask for a printed copy of
our Notice at any time. You may ask us to restrict the use and disclosure of certain
information in your records that otherwise would be disclosed for treatment, or health
care operations; however, we do not have to agree to these restrictions. If we do agree
to a restriction, that agreement is binding. You may revoke this consent at any time by
giving written notification. Such revocation will not affect any action taken in reliance on
the consent prior to revocation. This consent is voluntary; you may refuse to sign it.
However, we are permitted to refuse to provide health care services if this consent is
not granted, or if the consent is later revoked.
I hereby consent to the use or disclosure of my Protected Health Information as
specified above:
Patient Name:__________________________________________________________
Signature of Parent/Guardian:_____________________________________________
Date:__________________
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CLIENT’S RIGHTS AND RESPONSIBILITIES
I have read my Rights and Responsibilities and fully understand the information contained
therein.
__________________________________
Parent/Legal Guardian Signature
_________________________
Date
I, the undersigned, certify that I (or my dependent) have insurance coverage with
_____________________________________________ and assign all insurance benefits (if
applicable) directly to Pinnacle Pediatric Therapy Group.
Please complete and return the Client Questionnaire along with the Patient Registration Form
and other documents to address below.
Thank you!
Pinnacle Pediatric Therapy Group
6215 Lorraine Road
Lakewood Ranch, FL 34202
(941) 758-4707
www.pinnacletherapy.net
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Pinnacle Pediatric
Therapy Group Client
Rights & Responsibilities
As a client of Pinnacle Pediatric
Therapy Group, or as a family
member or guardian of a client,
we want you to know that we are
committed to honoring your
rights. By taking an active role in
your therapy, you can help your
providers to meet your needs.
• A decision to not take part in
research or clinical trials will
not affect your right to receive
treatment.
You have the right to receive
treatment without discrimination
due to age, sex, race, or gender.
• Know the names and
credentials of providers who are
treating you.
Rights
You have the right to:
• Receive information in a way
that you understand.
• Receive information about your
current treatment plan, outcomes, and recommendations.
• Be informed about proposed
treatment options including the
risks and benefits, other options,
what could happen without
treatment, and the outcomes of
treatment.
• Be involved in all aspects of
treatment and take part in
decisions about treatment.
• Expect the provider to get your
permission before taking photos,
recording, or filming you/your
child for the purpose of training,
education, or media.
• Decide to take part in research
or clinical trials related to
treatment. Your participation is
voluntary, and written permission
must be obtained from you
before you participate.
• Receive kind, respectful, safe,
quality care delivered by skilled
professionals.
• Receive efficient and quality
care with high professional
standards that are continually
maintained and reviewed.
• Expect all communications and
records related to treatment to be
treated as private and
confidential.
• Receive written notice that
explains how your information
will be used and shared with
other health care professionals
involved in your treatment.
Responsibilities
We ask that you:
• Provide accurate and complete
information about current health,
education, and behavioral
information.
• Provide a copy of any recent
evaluations, diagnosis, medical
records, or other health/
educational documentation that
is important to treatment.
.
• Recognize and respect the
rights of other clients, families,
and providers. Threats, violence,
or harassment will not be
tolerated.
• Comply with the agency’s no
smoking policy.
• Be actively involved in your
child’s treatment by participating
in education, training, and
observation of sessions as
recommended by your provider.
• Review and request copies of
your treatment records unless
restricted for legal reasons.
• Ask questions if you are
concerned about your treatment.
• Review, obtain, request, and
receive a detailed explanation of
your treatment charges and bills.
• Are responsible for paying your
bills related to services rendered
in a timely manner.
• Report any concerns or
complaints regarding your
treatment to the agency Director.
This will not affect your future
care.
• Follow your treatment plan as
developed by your provider(s)
and participate in the
development of your child’s
treatment plan.
• Expect a timely response to
your complaint or grievance for
the agency Director. This may be
made in writing, by phone, or in
person.
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Thank you!
Pinnacle Pediatric Therapy
Group