New Client Intake Form

Questions? Contact us! info@jstherapies.com

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

Child's name

Date of birth

Gender

Female Male

Clinic Location

St. Croix St. Thomas

Services Requested

Occupational Therapy

Speech Language Therapy

Physical Therapy

Parent/Guardian 1

Parent/Guardian 2

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

School/Daycare

Grade

Teacher/Daycare provider

May we communicate and collaborate with your child's school staff about services & recommendations?

Yes No

Primary Language spoken at home:

Secondary Language spoken at home:

Interpreter needed?

Yes No

Medical Information

Primary Care Physician/Pediatrician

Referred by:

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

Yes No

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, IEPs, medical records with us here:

Add file

Please upload a file

Insurance Information

Does the child 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.

MAP Member ID Number

Does your child have any other health insurance coverage?

Yes No

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.

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

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

Parent Questionnaire

Please describe any important illnesses, injuries or surgeries, including birth complications, colic, ear or chest infections, etc. and the ages at which they occurred.

At what age (in months) did your child:

Sit alone

Creep/Crawl

Walk alone

Say 1st word

Other OT areas of concern not listed above:

See our complete Does My Child Need OT checklists here.

AREAS OF CONCERN: Speech Language Therapy

My child isn't talking yet

It is difficult to understand my child

Other people have difficulty understanding my child's speech

Specific speech sound delays

My child doesn't communicate at all

None of these

Other Speech/Language areas of concern not listed above:

Other PT areas of concern not listed above:

Does your child currently receive any other services?

Special Education

Occupational Therapy

Speech Language Therapy

Physical Therapy

Counseling

Behavior Interventions (ABA)

What other evaluations, therapy or special programs has your child had in the past and when?

What would you like us to know about your child? 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?

Pediatrician

Other Medical Professional

Teacher/Daycare staff

Friend/Family

Social Media

Internet Search

Other

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, 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 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 when they meet milestones, graduate from therapy, or are having fun?

Yes No

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

I consent:

Yes No

School staff

School/teacher name or NO CONTACT

Doctor

Doctor name or NO CONTACT

Other

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.

COMMUNICATION: I authorize my child’s therapists 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 for my child. 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!

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