New Client Intake - Lactation Support

Questions? Contact us! info@jstherapies.com

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

Baby First Name

Baby Last Name

Date of birth

Gender

Female Male

Clinic Location

St. Croix St. Thomas

Services Requested

Lactation Support

Occupational Therapy

Speech Language Therapy

Physical Therapy

This is our intake form for Lactation Support only. Please complete our regular Child Intake Form to request Occupational Therapy, Speech Language Therapy, or Physical Therapy.

Parent/Guardian 1 First & Last Name

Parent/Guardian 2 First & Last Name

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

Have you taken any other prenatal classes? If so, please specifiy:

Have you nursed any previous children?

Yes No

Did you have any difficulty?

Yes No

How long did you nurse them for?

Medical Information

Primary Care Physician/Pediatrician

Referred by:

OB/Midwife

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

Yes No

How many wet diapers did your baby have in the last 24 hours?

How many poopy diapers did your baby have in the last 24 hours?

What is the color and consistent of your baby's stools (poop)?

Birth weight:

Lowest weight:

Last known weight:

Any diagnosed medical conditions?

Other Condition/Diagnosis

Current Medications or supplements

History: Pregnancy and Labor & Delivery

Any irregularities or concerns with your menstrual cycle?

Yes

Any challenges with fertility?

Yes

Additional information:

List any other conditions here:

How was baby born?

Vaginal birth Unplanned c-section Planned c-section

How many weeks gestation?

Full term or premature?

Epidural or pain medication?

Please describe any complications at birth for mom or baby:

Current birth control method:

You can securely share any medical records or other documents with us here:

Add file

Please upload a file

Postpartum

How is your recovery going?

If other, please list below:

What level of support do you have?

Partner

Spouse

Family Members

Friends

No Support

Other:

If other, please list below:

Feeding History

Did your baby latch within the first 2 hours after birth?

Yes No

Describe any lactation support you have received thus far:

Has your baby received a diagnosis of:

Tongue Tie Lip Tie Cheek Tie N/A

If your baby has had a tongue tie procedure, please list the name of the provider and the date of the procedure:

What are your current feeding goals?

Exclusive nursing

Exclusive pumping

Exclusive infant formula

Nursing + bottles (expressed breastmilk)

Nursing + bottles (infant formula)

Nursing + bottles (no preference of breastmilk or formula)

If Other, please explain:

How is your baby currently being fed?

Exclusive breastmilk Combination of breastmilk & formula Exclusive formula

How many times has your baby latched directly to the breast in the past 24 hours?

None 1-2 3-4 5-6 7-8 8+

Bottle Feeding

N/A

Bottle Brand:

Nipple Flow:

# of oz per day:

# of minutes to finish bottle:

If Other, please list:

Infant Formula

N/A

Formula Brand:

# oz/bottle

# oz/day

Using to thicken or fortify?

Yes No

Additional information about formula experience:

Pumping

N/A

Brand:

# pumps per day

# of minutes

# oz/day

Any additional details you would like to share?

Insurance Information

Does your baby have insurance coverage?

Yes No Not yet, but will M.A.P.

Does mother have insurance?

Yes No MAP

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

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?

Pediatrician

Other Medical Professional

Friend/Family

Social Media

Internet Search

Other

If Other, please list:

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

Consent Form

CONSENT FOR CARE AND TREATMENT: As the child’s parent/legal guardian, I hereby grant permission for the therapists at JS Therapies, LLC to provide routine therapeutic care to my child and myself, including evaluations, therapeutic/educational activities, & other procedures and/or treatments prescribed by my child’s 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 protected medical information about myself and my child is used or disclosed.

I understand.

PHOTOGRAPHY RELEASE: We love sharing success stories!! May we use a photo of your child on our website or social media with your verbal permission to approve the specific photo?

Yes No

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

I consent:

Yes No

Pediatrician

Doctor name or NO CONTACT

OB/GYN

Doctor name or NO CONTACT

Other

Family, other professionals

This authorization is valid for the duration of 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 therapist to communicate with myself and the above-named individuals, regarding treatment recommendations and scheduling for my child, 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 children and collect patient balances in a way that is efficient and convenient for families.

Our Patient Accounts Manager collects co-pays monthly via credit/debit card.

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 receiving services at school, home, or daycare.

Please feel free to contact our patient accounts 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 863-513-4182.

Signature of parent/legal representative of child

Date

Credit Card Authorization Form

Credit card on file will be charged monthly for co-pay/self-pay balance and receipt will be emailed.
If you do not have a required co-pay, your card will ONLY be charged if you violate the attendance policy by cancelling your appointment with less than 24 hour notice. Contact Staci (staci@jstherapies.com or 863-513-4182) 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 your child reach their potential!

Email address

Your information will be encrypted.