New Client Intake Form ADULT

Questions? Contact us! info@jstherapies.com

Please have your insurance policy information available to complete all fields in this form.

Name

Date of birth

Gender

Female Male

Clinic Location

St. Croix St. Thomas

Services Requested

Occupational Therapy

Speech Language Therapy

Physical Therapy (STT only)

Primary phone number

Alternate phone number

Email address

Alternative email address

Mailing Address

City

Zip Code

Physical Address (If Different)

City

Zip Code

Emergency Contact

Emergency Contact Phone Number

Level of Education

May we communicate and collaborate with your doctor about services & recommendations?

Yes No

Medical Information

Primary Care Physician

Referred by:

May we communicate with your doctor about the evaluation results and treatment plan?

Yes No

Medical Conditions/Diagnoses

None/Not Applicable

Acquired Brain Injury

Stroke

Parkinson's Disease

Dementia

Multiple Sclerosis

Cerebral Palsy

Other condition not listed

Please provide details below.

Other Condition/Diagnosis

Current Medications

Other Condition/Diagnosis

Current Medications

Allergies

Dietary Restrictions

Hearing

Normal Impaired Not tested

Vision

Normal Impaired Not tested

You can securely share any prior evaluations or medical records with us here:

Add file

Please upload a file

Insurance Information

Do you have insurance coverage?

Yes No M.A.P.

For families without insurance, we do offer self-pay rates and have financial assistance available. Please see the Financial Aid Policy & Application on our website and contact us for details.

Insured's Name

Insured's Date of Birth

Primary Insurance Company

Employer

Policy Number

Group Number

Is there a secondary insurance policy?

Yes No

Secondary Insurance Company

Employer

Insured's Name

Insured's Date of Birth

Policy Number

Group Number

MAP Member ID Number

I authorize our insurance benefits to be paid directly to JS Therapies. I also authorize JS Therapies or our insurance company to release any information required to process our claims. I agree to pay denied by my insurance carrier, including, but not limited to: non-covered services, deductibles, co-pays, and services exceeding maximum benefit limits.
I shall promptly notify JS Therapies of any changes in Insurance coverage.

Signature

Date

Questionnaire

Please describe any important illnesses, injuries or surgeries and the ages at which they occurred.

Other areas of concern not listed above:

Do you currently receive any other services?

Occupational Therapy

Speech Language Therapy

Physical Therapy

Counseling

What other evaluations, therapy or special programs have you had in the past and when?

What would you like us to know about you? What are your biggest concerns?

Do you have any preferred days/times for regular weekly appointments?

Please specify if there are any days/times you are NOT available.

How did you hear about us?

Doctor

Other Medical Professional

Friend/Family

Social Media

Internet Search

Other

Who can we thank for referring you? (or N/A)

Consent Form

CONSENT FOR CARE AND TREATMENT: I hereby grant permission for the therapists at JS Therapies, LLC to provide routine therapeutic care, including evaluations, therapeutic/educational activities, & other procedures and/or treatments prescribed by my therapist as is necessary in their judgment.

I consent.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES: I acknowledge that JS Therapies, LLC will use & disclose my personal health information for treatment, payment, & other healthcare operations and as otherwise permitted by law. I understand that I may request a copy of the Notice of Privacy Practices to provide further detailed information about how my protected medical information is used or disclosed.

I understand.

RELEASE OF INFORMATION: I also allow the release of my medical information to the following individuals:

I consent:

Yes No

Doctor

Doctor name or NO CONTACT

Other

Family, other professionals

This authorization is valid for the duration of my treatment from the date signed below. I understand that I may revoke this authorization at any time, but will not hold JS Therapies responsible for already releasing information in good faith.

COMMUNICATION: I authorize my therapists to communicate with myself and the above-named individuals, regarding treatment recommendations and scheduling, via:

Text/Email I do not authorize communication via text or email.

ATTENDANCE/CANCELLATION POLICY (click to read)

I have read and reviewed the Attendance/Cancellation Policy and understand the importance of consistent attendance and advanced notice for cancellations.

Initials

Signature

Date

Financial Agreement

JS Therapies is committed to working with families to maximize service provision for all clients and collect patient balances in a way that is efficient and convenient for families.

Please choose one of the following options:

Credit card to be billed monthly for co-pays or self-pay charges.

CC authorization form must be on file. If card is declined more than 2 times and client does not respond within 1 week to pay balance, $25 per week will be charged until balance is paid. Credit card option is mandatory for those who receive services outside of the clinic..

Pay at Session. Client is responsible for payment at the front desk (or via online payment link) at time of service.

If client does not pay at session, card on file will be charged for co-pay. Clients who receive services in the community must have CC on file.

Our billing is managed through the St. Croix clinic, so Pay at Session is not yet an option for STT clients.

Credit card to be billed monthly for co-pays or self-pay charges.

Please feel free to contact our billing manager if you have any questions about this policy, or if you are experiencing financial hardship and would like to discuss an alternative payment arrangement.

Staci Davidson: staci@jstherapies.com or 340-473-5924.

Signature

Date

Credit Card Authorization Form

Credit card on file will be charged monthly for co-pay/self-pay balance and receipt will be emailed. Contact Staci (staci@jstherapies.com) with any questions or to make alternative arrangements.

Card Type

VISA MASTERCARD DISCOVER AMERICAN EXPRESS

Cardholder Name (as shown on card)

Card number

Security Code

Expiration Date (mm/yy)

Billing ZIP code

Email address

I authorize JS Therapies to charge my credit card for therapy services. I understand that my information will be saved to file for future transactions on my account.

Signature

Date

This authorization can be cancelled at any time by contacting our office.

Thank you for choosing JS Therapies, we look forward to helping you reach your potential!

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