Child Admission Packet - Speech Therapy Services, P.C.

Child Case History
Patient Identifying Information
Patient Name
First Middle Initial Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Alternate Phone
Date of Birth
MM slash DD slash YYYY
Doctor
SS#
Insurance
Number
Parent/Guardian Information
****Please list two contacts
Parent/Guardian 1 Name
First Last
DOB
MM slash DD slash YYYY
Relation
Home Phone
Cell Phone
Alternate Phone
Parent/Guardian 2 Name
First Last
DOB
MM slash DD slash YYYY
Relation
Home Phone
Cell Phone
Alternate Phone
Has your child been referred to or is currently being served by Babies Can’t Wait?
- Yes
- No
Does he/she have an IEP/IFSP?
- Yes
- No
Names and ages of other children in family:
NAME SEX AGE SCHOOL/GRADUATE
NAME SEX AGE SCHOOL/GRADUATE
NAME SEX AGE SCHOOL/GRADUATE
NAME SEX AGE SCHOOL/GRADUATE
NAME SEX AGE SCHOOL/GRADUATE
History of Speech Problem
Describe child's speech problem as it appears to you.
When was the problem first noticed?
By whom?
Describe any change in the problem since it began.
Has child ever had any speech or language testing or therapy?
- Yes
- No
Where?
Date Began:
MM slash DD slash YYYY
Date Ended
MM slash DD slash YYYY
Results
Does anyone in the household speak a language other than English?
- Yes
- No
What language?
Please check behaviors that describe your child:
- Looks happy
- Appears sad
- Non-Compliant
- Exhibits one or more, rocking, hand flapping, twirling
- Even Tempered
- Is affectionate
- Throws/breaks
- Cries frequently
- Very Active
- Calm and Quiet
- Self-Injurious
- Has trouble sleeping
- Friendly/outgoing
- Very Independent
- Distractible
- Seems Unusually fearful
- Dependent on adults
- Aggressive to others
- Tantrums/Screaming
- Picky Eater
- Plays well with peers
- Climbs with no fear
- Prefers to play alone
- Doesn’t respond normally to pain
- Jibberish/Jargon speech
- Walks on tiptoes
- Poor eye contact
- Sensitive to noise
- Sensitive to smell
- Difficulty transitioning from one activity to another
Medical History
Birth History
Pregnancy Was:
- Normal
- Complications
Explain Complications
Term Length?
- Full Term
- Premature
Describe
Please list and describe any accidents, operations or hospitalizations you child has had:
Developmental Milestones
Motor Milestones
at what age did the following occur?
Rolled over alone
Crawled
Walked Unaided
Toilet Trained
Sat Alone
Stood Alone
Fed with Spoon
Dressed/Undressed Self
Speech-Language Milestone
Did child make cooing or babbling sounds during first 6 months?
- Yes
- No
When did your child say first words?
What were your child's first words?
At what age did child begin to put 2 or 3 words together?
Does child prefer to talk or gesture?
- Talk
- Gesture
Does your child understand what you say to him/her?
- Yes
- No
Will child get common objects when asked?
- Yes
- No
Fluency Development (for stuttering only)
Does your child stutter?
- Yes
- No
Is there a concern about voice quality?
- Yes
- No
Does your child exhibit any of the following:
- Hoarseness
- Harshness
- Too Loud
- Too Soft
- Pitch Breaks
- Loss of Voice
Are you concerned about child’s ability to chew, swallow foods and/ or liquids?
- Yes
- No
Does your child exhibit any of the following:
- Coughing Strangling
- Pocketing Food in Mouth
- Throat Clearing
- Excessive Drooling
- Other
Describe
Please check any illnesses your child had/has and include age at which illness occurred
- Adeniodectomy
- Convulsions
- Ear Infection
- Tonsillectomy
- Allergies
- Ear Ache
- Pneumonia
- Food Allergies
Age of Occurrence for Adeniodectomy
Age of Occurrence for Convulsions
Age of Occurrence for Ear Infections
Age of Occurrence for Tonsillectomy
Age of Occurrence for Allergies
Age of Occurrence for Ear Aches
Age of Occurrence for Pneumonia
Please list food Allergies
General Health
General Information
How would you rate your child's general health?
- Good
- Fair
- Poor
Is your child presently on any medication? If so, please list all:
Any recent changes in medication or new diagnosis?
Hearing Development
Are you concerned about your child's ability to hear?
- Yes
- No
Does your child react consistenty to sound?
- Yes
- No
Is your child overly sensitive to noise?
- Yes
- No
Can your child turn to the direction from which a sound is coming? (i.e. turns head toward radio when it's turned on by someone else.)
- Yes
- No
Does your child have frequent ear infections?
- Yes
- No
Please describe any treatment he/she has received for ear infections.
Does your child wear a hearing aid?
- Yes
- No
When was your child fitted for hearing aid?
Has your child’s hearing been screened/tested? If so, please list all.
Print Name
Parent/Guardian Signature
Date Signed
MM slash DD slash YYYY
*** INFORMATION AND CONSENT ***
First M.I. Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone Number
Other Phone Number
Cell Phone Number
DOB
MM slash DD slash YYYY
Doctor
SS#
Primary Insurance Name:
Number
Medicaid/Peach State Number/Wellcare Number
Is it ok for STS to contact you by text?
- Yes
- No
Individual Education Plan (IEP) and Individualized Family Service Plan/IFSP (Children Only)
If this patient has an IEP/IFSP, we must provide a copy. Choose all that apply.
- My child is being served by Babies Can't Wait/Early Intervention.
- My child has an IEP/IFSP.
- I am attaching my child's IEP/IFSP from his/her local school agency.
- My child does not have an IEP/IFSP.
- I request that my child's speech therapy services be provided at the daycare if possible.
NAME OF DAYCARE
Notice of Privacy Practices:

Speech Therapy Services, P.C. (STS) is required to provide our patients with a privacy notice regarding our legal duties and policies to protect your health privacy. Our practice is dedicated to maintaining the privacy of your individual identifiable health information (IIHI). This notice serves to inform you that STS uses your personal health information primarily for treatment, obtaining payment, and consulting with necessary health and educational members of this facility, including your doctor and his/her staff. You may obtain a complete copy of our office procedures and privacy practices at any time by contacting our office at the above location. If you have any questions or concerns, do not hesitate to call the speech therapy office at 246-4088.

Consent for Treatment and Billing:

I have read and understand the process of speech therapy services, including evaluation, treatments, attendance policies and privacy policies at STS. I give permission for STS to evaluate and provide speech therapy services to the patient listed above as indicated. I authorize the staff at STS to discuss protected health information with this patient's caregivers, as listed below, physicians and insurance company as needed to ensure coordination of services and quality care. I authorize STS to follow the necessary steps to bill this patient's insurance company including the release of information to insurance providers as needed for the billing for services provided. I understand I am responsible for all charges at the time services are rendered and if my insurance is billed, I am responsible for all unpaid balances.

I give permission for the staff at STS to discuss protected health information with the following people:
NAME RELATIONSHIP
NAME RELATIONSHIP
NAME RELATIONSHIP
NAME RELATIONSHIP
NAME RELATIONSHIP
NAME RELATIONSHIP
Patient Signature or responsible party
Print Name
Authorization to Obtain/Release Confidential Information
Name
First Last
DOB
MM slash DD slash YYYY
I HEREBY REQUEST AND AUTHORIZE:
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Relationship
TO OBTAIN FROM OR RELEASE TO:
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Relationship
The Following Information:
For The Purpose Of:
All Information I Hereby Authorize To Be Obtained From/By This Agency Will Be Held Strictly Confidential And Cannot Be Released Again Without My Written Consent. I Also Authorize The Use Of Clinical Observation And Case Discussion For Professional Purposes.
Signature of Patient or Guardian
Date
MM slash DD slash YYYY
Relationship to Patient
THERAPY ATTENDANCE POLICY AND GUIDELINES
Regular and consistent treatment plays a critical role in your child’s progress and ability to achieve goals. In order to help your child achieve their goals and receive high-quality therapy services, we have established an attendance policy and guidelines to help ensure that every child receives the time and attention they deserve. Please initial that you have read each guideline.
Please arrive on time for therapy sessions. If you are tardy, your child’s therapy session cannot be extended to accommodate your late arrival.
If you need to cancel an appointment, please call our front office 24 hours in advance to notify us at (229) 246-4088. We will attempt to re-schedule your appointment whenever possible. If your call is not during our normal business hours, please leave a message with our voicemail messaging system. Speech Therapy Services reserves the right to assess a $45.00 cancellation fee for appointments cancelled with less than 24-hour notice.
Patients who miss 3 scheduled appointments without advanced notice (no call/no show) and/or frequently missed appointments, will be removed from the current patient rotation and placed on a waiting list. Their physician will be notified.
Repeated cancellations or no shows will be reported to your referring physician and may result in discontinuance of therapy.
Parents should not leave the premises during their child’s appointment.
I have read and understand Speech Therapy Services’ Attendance Policy and Guidelines and agree to comply.
Child's Name
Parent/Guardian Signature
Date
MM slash DD slash YYYY
Untitled
CAPTCHA

Child Case History

Patient Identifying Information

Parent/Guardian Information

History of Speech Problem

Medical History

Birth History

Developmental Milestones

Motor Milestones

Speech-Language Milestone

Fluency Development (for stuttering only)

General Health

General Information

Hearing Development

*** INFORMATION AND CONSENT ***

Notice of Privacy Practices:

Consent for Treatment and Billing:

Authorization to Obtain/Release Confidential Information

THERAPY ATTENDANCE POLICY AND GUIDELINES

* INFORMATION AND CONSENT *