Metro Therapy Special Children's Clinic, Inc.

Person completing the form

Patient Information

Patient/Child's Name (Last, First MI)

Street Address

City

Zip Code

Sex

Female Male

Date of Birth

Mobile Phone Number

Can we send text reminders/updates?

Yes No

Email Address

Can we contact you by email?

Yes No

Parent 1 Name

Phone Number

Lives with?

Yes No

Parent 2 Name

Phone Number

Lives with?

Yes No

Emergency Contact Name (Local friend/relative NOT at same address)

Phone Number

Relationship

Child's Primary Care Physician

Primary Physician Name

Clinic

Phone Number

Insurance Information

Primary Insurance

Group #

Policy #

Policy Holder Name

Policy Holder Date of Birth

Secondary Insurance

Group #

Policy #

Policy Holder Name

Policy Holder Date of Birth

I AGREE TO PAY Metro Therapy Special Children's Clinic for the services provided.
I am responsible for all charges regardless of insurance coverage and whether or not paid by my insurance company.
I understand that I am responsible for contacting my insurance company to verify therapy benefits.
I am also responsible to confirm the required referral or authorization with my insurance company prior to receiving therapy services.
I am responsible for any denied charges. I am liable for all charges my insurance denies that are the result of changes to my insurance policy or company charges.
I consent for this provider to render treatment.
I give authorization to be treated within the therapy clinic in areas not totally isolated from other patients and personnel.
This authorization or photocopy will authorize the release of any medical information necessary to treat you and/or to process claims for services rendered by this provider to the patient's physician or 3rd party payer that is stated on this form.
I request and authorize my insurance company and/or M.A. to make payments to authorized benefits on my behalf to this provider.
I understand the information provided above and I have provided accurate information to the best of my knowledge.
I have received a copy of Metro Therapy Special Children's Clinics, Inc. Notice of Privacy Practices.

Name

Date

General Information

Child's Race (Caucasian, African American, Hispanic, Asian, Etc)

Is the child adopted?

Yes No

Foster Child?

Yes No

Parents are:

Married Separated Divorced Single Widowed Partnered

Other primary caregivers in household (step-parent or grandparent)

What languages are spoken at home?

Who in the household speaks other languages?

What languages does your child understand?

What languages does your child speak?

Does your child require an interpreter?

Yes No

If so, what language?

Are there any religious or cultural preferences we should be aware of?

School Information

School your child attends

Teacher name

Grade

Does your child currently have an IEP or IFSP?

Yes No

If yes, please bring a copy of the IEP/IFSP to your child's evaluation.

Educational diagnosis indicated on IEP/ISFP

If your child is not attending school how does he/she spend his/her time (daycare, at home, work)?

Medical Information and Secondary Physicians (if any)

Medical Diagnosis (if any)

None

Autism Spectrum Disorder

ADHD

Anxiety

Seizure Disorder

Down Syndrome

Cerebral Palsy

Developmental Delay

Other

Add another

Has your child previously received evaluations or treatment by other specialists (psychologist, allergist, gastroenterologist, neurologist, etc.)?

Add new

Has your child previously received an evaluation and/or treatment by an occupational therapist?

Yes No

If yes, when and where?

Has your child previously received an evaluation and/or treatment by a physical therapist?

Yes No

If yes, when and where?

Has your child previously received an evaluation and/or treatment by a speech therapist?

Yes No

If yes, when and where?

Date of last vision test

Finding

Date of last hearing test

Finding

Has your child had any of the following? If yes, please describe and provide approximate dates.

Childhood disease or illness

Congenital abnormalities

Surgery

Serious injury

Ear infections

Tubes in ears

Allergies

Other

Please list any medications your child is CURRENTLY taking, its purpose and frequency of the dosage.

Add another medication

Are there any precautions the therapist should be aware of when working with your child?

Are there any safety concerns the therapist should be aware of when working with your child?

Does your child have any assistive devices (ex: glasses, braces, wheelchair, hearing aid)?

Does your child experience any pain? If so, where and how often?

Pregnancy and Child's Birth

Please list and describe any complications during pregnancy (ex: preeclampsia, use of medications, drug/alcohol use, etc.)

Was your child born full term?

Yes No

If born prematurely, at how many weeks gestation was the birth?

Child's weight at birth

Was your child born via Caesarean section?

Yes No

Please list and describe any complications, injuries, or extended hospitalization associated with your child's birth.

Motor Development

Please provide the age at which your child:

Rolled over

Sat alone

Crawled

Walked

Please provide how well your child can do the following:

Speech-Language Development

Did your child coo or babble as an infant?

Yes No

At what age did your child speak his/her first word?

At what age did your child begin to put words together?

At what age did you first become concerned about your child's speech/language?

Do you feel your child typically understands what is said to him/her?

Yes No

How does your child typically let you know when he/she wants or needs something? Examples could include crying, making gestures, speaking single words, short phrases, or sentences.

If your child typically uses words or sentences, is he/she difficult to understand?

Yes No

If yes, is he/she difficult for you to understand?

Yes No

If yes, is he/she difficult for others to understand?

Yes No

What about his/her speech is difficult to understand

What percentage of your child's speech do you understand?

What percentage of your child's speech do other close family members/friends understand?

What percentage of your child's speech do unfamiliar people understand?

Describe how your child interacts with others: (shy outgoing, aggressive, imitates, plays along with others, etc.)

Please indicate any other communication concerns you have regarding your child

Functional Goals

What are some of the functional outcome goals you would like to have for your child as a result of direct SPEECH-LANGUAGE THERAPY? (goals should be related to home/school/community in the areas of communication, play, social interaction, etc.)

Add another goal

What are some of the functional outcome goals you would like to have for your child as a result of direct OCCUPATIONAL THERAPY? (goals should be related to home/school/community in the areas of play, daily living skills, school, work, etc.)

Add another goal

What are some of the functional outcome goals you would like to have for your child as a result of direct PHYSICAL THERAPY? (goals should be related to home/school/community in the areas of play, daily living skills, school, work, etc.)

Add another goal

Metro Therapy Special Children's Clinic, Inc. Authorizations

Emergency Medical Release

Should it become necessary, I authorize Metro Therapy to pursue emergency medical treatment for my child.

Photo Authorization

By checking this box, I authorize my child to be photographed and the release of those photographs to be used as part of Metro Therapy’s website and/or in the physical clinic space.

Toileting Information and Authorization to Assist

For the comfort and safety of your child and our staff, please indicate your child’s current toileting status:

Fully toilet trained with no assistance needed. Fully toilet trained, but may need some assistance (wiping, unbuttoning pants, etc.) In the process of toilet training, needs reminders to use the bathroom Not toilet trained, uses diapers/pull-ups

Name

Date

Patient Release and Authorization

I, (Parent), authorize the use and/or disclosure of health information as set forth below for (child).

Parent's Name

Child's Name

1. The following health information may be used and/or disclosed pursuant to this authorization:

Check all that apply

Medical Records

Health Information

IEPs/Plans of Care/Evaluations

2. I authorize Metro Therapy to receive/give health information regarding this child.

3. I authorize the following person(s) or class of person(s) to receive/give health information concerning this child:

Physician

Clinic

Phone Number

School

School District

Phone Number

Social Worker

Organization

Phone Number

Outside Services

Organization

Phone Number

Other

Organization

Phone Number

4. I understand I have the right to revoke this authorization at any time, except to the extent that the person(s) or class of person(s) to whom I have authorized such use and/or disclosure have acted in reliance upon this authorization. In order to revoke this authorization, I must provide Metro Therapy S.C.C., Inc. in writing specifically revoking this authorization.

5. I understand that my health information may no longer be protected by the federal privacy protection regulations, 45 C.F.R. parts 160 and 164, if my health information is used or disclosed pursuant to this authorization.

6. I acknowledge that I have been provided with a Notice of Privacy Policy either electronically or in person and agree to the terms therein.

Name

Date

Authorized Pick Up

We understand that children may be picked up by adults, other than their parent and/or guardian. In order to protect your child, we are asking that you let us know, in advance, if you will have someone picking your child up from Metro Therapy. You may pre-authorize adults by completing the information below. Please let the authorized person know that photo identification may be required if a staff member is unfamiliar with them.

Add another person

I authorize the above person(s) to pick up my child from Metro Therapy. I understand this permission will be in place until I communicate a change, in writing, to Metro, and Metro will not release my child to anyone that is not listed without my written ( or verbal) consent.

Name

Date

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