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?

Please list who lives in the child’s household

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

School Information

School:

Grade:

Daycare:

Days per week:

Hours per day:

Does your child currently have an IEP or IFSP?

Yes No

504 Plan?

Yes No

Referred by

Doctor Therapist Teacher Self-referral Other

If other:

Referred for

Speech Therapy Occupational Therapy Physical Therapy Feeding Social Skills/Group

Medications

Medication Name

Dosage

Reason

Medication Name

Dosage

Reason

Allergies

Miscellaneous

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

Yes No

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

Yes No

If yes, please explain:

Does your child receive the following outside services?

Please explain any complications during pregnancy or birth.

Please list significant medical history, including approximate date or year. (Examples: surgeries, PE tubes placed, tonsils removed, webbed fingers, etc.)

PHYSICAL THERAPY

Motor Milestones

Physical Development

Strongly favors looking to one side, but not the other (for infants)

Yes No

Prefer to “W” sit

Yes No

Walks on their tiptoes the majority of the time

Yes No

Frequently trips or falls

Yes No

Trouble keeping up with other kids on the playground

Yes No

Concerns with bowel or bladder control. (Day or Nighttime)

Yes No

Complains of pain frequently (foot, ankle, knee, hip, back, neck)

Yes No

SPEECH-LANGUAGE PATHOLOGY

Speech-Language Development

My child cooed or babbled as an infant.

Yes No

My child typically understands what is said to him/her.

Yes No

It is difficult for other people to understand my child’s words and sentences.

Yes No

It is difficult for me to understand my child’s words and sentences.

Yes No

I can understand 50% or more of what my child says.

Yes No

I can understand 80% or more of what my child says.

Yes No

Other people can understand 50% or more of what my child says.

Yes No

Other people can understand 80% or more of what my child says.

Yes No

My child yells or cries to communicate a need.

Yes No

My child approaches or touches me to communicate a need.

Yes No

My child becomes physical to communicate a need (hit, throw, etc.)

Yes No

Please provide any additional details about your concerns with your child’s communication?

Speech-Language Development

What age did your child speak their first word?

What age did your child start to put together words?

What age did you became concerned about your child’s speech and language development?

Please indicate how your child plays or interacts with others. Check all that apply:

Shy

Imitates others

Outgoing

Plays along with other children

Aggressive/Plays rough

Prefers to play alone

Easily frustrated with peers

OCCUPATIONAL THERAPY

Fine Motor Skills

Select all that apply:

Difficulty eating with utensils at meal time

Difficulty snipping or cutting with scissors

Difficulty drawing basic shapes: line, circle, +, square

Difficulty with writing name or handwriting

Difficulty opening age-appropriate lids or containers

Difficulty keeping body still for seated tasks

Difficulty with tasks that use both hands

Self-Care

Do you have concerns for your child in any of the following tasks? Select all that apply.

Undressing self

Dressing self

Clothing fasteners (zippers, snaps, buttons)

Taking off socks or shoes

Putting on socks or shoes

Bathing

Eating or mealtimes

Getting haircuts

Getting hair brushed or styled

Getting fingernails clipped

Brushing teeth

Sleep or bedtime

Using toilet

Please provide detail on any of the above checked areas:

Emotional Regulation

Check all that apply

Difficulty managing transitions

Difficulty accepting a change in routine

Difficulty accepting “no”

Difficulty making or maintaining friendships

Frequently or easily frustrated

Has frequent tantrums or meltdowns

Family life is stressful due to emotional regulation difficulties

Feeding

Stressful or difficulty with food intake during infancy

History of acid reflux

Eats less than 20 different foods

Is a picky eater

Will eliminate foods from diet that were previously enjoyed

Has meltdowns surrounding meal times

Has strong preferences for certain food groups, food textures, or brands

Has food sensitivities or food allergies.

What are you most hoping to gain out of therapy?

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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