New Client Intake Form

JS Therapies

Please correct the errors described below.

Medical Information

    Please upload a file

    Insurance Information

    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.

    If your child is also covered by another health insurance, you are required to provide this information. If MAP is active, it will cover any co-pays or costs not covered by your primary health insurance. You are responsible for ensuring that your coverage remains active/renewed to avoid any out-of-pocket costs.

    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.***

    Parent Questionnaire

    At what age (in months) did your child:

    See our complete Does My Child Need OT checklists here.

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

    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, including evaluations, therapeutic/educational activities, & other procedures and/or treatments prescribed by my child’s therapist as is necessary in their judgment.

    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 my child is used or disclosed.

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

    School/teacher name or NO CONTACT
    Doctor name or NO CONTACT
    Family, other professionals

    This authorization is valid for the duration of my child’s 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.

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

    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.

    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: or 863-513-4182.

    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 ( or 863-513-4182) with any questions or to make alternative arrangements.

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

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

    Your information will be encrypted.