State: Zip Code: Home Phone#: Child resides with: Both Parents Mother Father Other Parent s address:

Transcription

1 Child s Name: Address: Today s Date: City: State: Zip Code: Home Phone#: Date of Birth: Age: Gender/Sex: Male Female Child resides with: Both Parents Mother Father Other Parent s address: Mother s Name: Home #: Cell#: DOB: Work #: Mother s Address: Father s Name: Home #: DOB: Cell #: Work #: Father s Address: (if different than patient s) BILLING GUARANTOR (HOLDER OF INSURANCE) Insured s Name: DOB: Employer Name: Phone #: Employer Address: Primary Ins. Company: PLEASE SIGN: I authorize the release of information necessary to file a claim with my insurance carrier and request payment of benefit to aim2achieve speech therapy or myself if fee has not been paid. I understand I am financially responsible for my balance not covered by my insurance carrier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits or the benefits payable for related services. Signature Date Referred by

2 Pediatric Speech History Patient s Name: Age Date Pediatrician s Name Phone: Pediatrician s Address Please send a report to my pediatrician Yes No Family History Mother s Name Age Occupation Education Level History of Speech, Language, or Hearing Problems: YES NO If yes, please explain Father s Name Age Occupation Education Level History of Speech, Language, or Hearing Problems: YES NO If yes, please explain Brothers and Sisters: Name Age Speech, Hearing or Medical Problems Is any language other than English spoken in the home? YES NO If yes please explain Mother s general health during pregnancy (illnesses, medication, etc.) Length of pregnancy: Length of Labor: General Condition: Birth Weight: Circle type of delivery headfirst feet first breech caesarean Was there any unusual condition that may have affected the pregnancy or birth: YES NO If yes, please explain Social History Does your child interact well with others his/her own age? Behavior problems? School Grade School Progress School your child is presently attending:

3 Hearing History Do you suspect your child has a hearing problem? YES NO If yes what behaviors lead you to this? Has any member of our family, or your child s teacher, every expressed concern about your child s hearing? Does your child have a permanent hearing loss that you are aware of? (For example: loss in one ear only, can t hear high pitch sounds) Do you question your child s ability to understand directions or conversations? YES NO If yes, what behaviors lead you to suspect this? Speech& Hearing History (Provide approximate age of acquisition) Coo and gurgle Babbling First word Name objects Combine 2-words Was he/she a vocally quiet baby? Did you hear a variety of sounds before his first words? Give examples of his first words Did/does your child prefer to point or use gestures? Make short sentences How would you describe your child s speech and or language problem? When did you first have concerns about his/her communication development? Does he/she have problems in understanding, expression, both? Explain: Do others have difficulty understanding your child? YES NO What have you tried to do to help? Has it improved his/her ability to communicate? Are there any factors that may be limiting your child s development? (attention span, behavior, illnesses, hospitalizations, etc?) Previous Interventions Has there been any prior interventions for your child s speech and language issue? For example: in-school therapy, prior private therapy, etc.

4 Developmental History (Provide approximate age of acquisition) At what age did your child walk? At what age did your child say his first word? Hold head up w/o support eat cereals & pureed foods night control Roll Over eat junior foods dress w/o help Sit up w/o support self-feed with finger foods color w/in outline Crawl drink from a cup tie shoelaces Stand alone bladder control use scissors Walk alone Describe any past or present feeding or sleeping problems: Is he/she left or right handed? Describe his/her motor skills? General Development Describe your child s general disposition: Is he/she consistent from day to day? Is/was your child ever over-sensitive to touch, sound, etc? Does your child enjoy play with other children? Describe child s general behavior: (shy, aggressive, hyperactive, kind, etc) Discipline used in home? Does discipline work with your child? Your child s favorite activities, playmates, TV shows, etc. General Health General health of the child High Fevers/Serious illnesses Seizures/convulsions Has the child had any surgeries? If yes, what type and when (e.g. tonsillectomy, adenoidectomy, and /or myringotomy with or without insertion of tympanostomy tubes etc.)? Describe any major accidents or hospitalizations

5 aim2achieve speech therapy Waiver While many insurance companies cover Speech Evaluations and Speech Therapy, I have been informed that some insurance companies do not. If my insurance company does not pay aim2achieve speech therapy for the services performed today, I understand that any charges incurred will be my financial responsibility. Please be advised that the benefit information that we obtained from your insurance company is not a guarantee of payment. The actual benefit information cannot be made until the insurance company receives the claim in their office. This would be subject to the patient s contract at time of service. I understand that I will also be responsible for any copay or coinsurance payment due to aim2achieve speech therapy at the time of service, per the requirements of my health insurance plan contract. Lastly, I understand that if I require a referral or precertification I am responsible for obtaining one. If I fail to do so, I will be responsible for the balances billed by aim2achieve speech therapy or outside parties for these services. Patient Signature Date

6 Private Practices Acknowledgement I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Signature: Date ******************************************************************************************************** Release of Information Patient s Name: I hereby authorize aim2achieve speech therapy to discuss, release & receive my medical information to the following: PHYSICIAN NAME: ADDRESS PHYSICIAN NAME: ADDRESS OTHER (PLEASE SPECIFY, NAME, ADDRESS, PHONE,) DATE WITNESS SIGNATURE OF PATIENT OR GUARDIAN RELATIONSHIP