Pediatric Speech-Language and Language Therapy Pediatric Occupational Therapy DIR /Floortime Therapy

Pediatric Speech-Language and Language Therapy Pediatric Occupational Therapy DIR /Floortime Therapy Thank you for your interest in our speech and language/occupational therapy and DIR Floortime services. This packet contains forms to be completed and returned by mail or fax prior to your appointment. Please return all forms by mail or fax one week prior to the evaluation or treatment date. Physician s script is required from all clients. If you have additional information, such as school or therapy reports, please forward those as well. Should you have questions about the completion of these forms, please call 713-522-8880. Please check which services you are requesting: Family First Speech Therapy, LLC. Kids Connect Occupational Therapy, LLC. Both Best, The Family First Speech Therapy Team Vanessa Chan-Felcman, M.A.CCC/SLP Kids Connect Occupation Therapy Team Michelle Reed, OTR/L 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 1

Attendance and Cancellation Policy CANCELLATIONS 1. Family First Speech Therapy, L.L.C. and/or Kids Connect Occupational Therapy, LLC. has a 24-hour cancellation policy, with regard to patient consultation and/or treatment sessions. Please let us know as soon as possible if it is necessary to cancel or re-schedule your child s session. Your advance notice enables us to offer the available appointment time to another client who needs extra therapy or a make-up session. We are happy to try to reschedule your child s appointment whenever possible. There is never a charge for canceling or rescheduling your child s session when adequate notice is provided, as long as you maintain a 75% attendance rate. 2. Cancellations well in advance may be made by e-mail, but please be sure that you receive confirmation. Cancellations made with less than 24 hours notice should be made by telephone (you may always e-mail in addition). 3. After 2 late cancellations or no shows, a $50 fee will apply. ILLNESS If your child wakes up sick, please call no later than 7:00am on the day of your appointment in order to avoid a no show. In order to keep everyone including therapist, other children and family members well, please keep your child home for 24 hours after the last occurrence of vomiting, diarrhea, or fever (without medicine). Use your best judgment if your child is sneezing, coughing, or has a drippy nose and is not able to cover a cough or use a Kleenex by him/herself. Child s name Parent s Name Date Parent s Signature 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 2

Acknowledgement and Assumption of Risk Date: I, (print name) acknowledge and agree to have my child, (print child s name) receive speech therapy/occupational therapy or DIR /Floortime services from employees or independent contractors of Family First Speech Therapy, LLC. and/or Kids Connect Occupational Therapy, LLC. I acknowledge that there is some risk inherent in the use of the therapy equipment and I agree to assume such risk and indemnify and hold Family First Speech Therapy, LLC. and/or Kids Connect Occupation Therapy, LLC. harmless from any and all losses and claims for any injuries or other damages occurring to myself, my child or our belongings. Signature Print Name 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 3

Credit Card/ Debit Transaction Processing Authorization Form (optional) Yes, I would like you to automatically charge my credit card for services rendered each month. Yes, I would like to have my checking account debited for services rendered each month. No, I would like to pay in person before every session. Card Type (circle one): Visa MasterCard Discovery Card Number: Expiration Date: CVV/CVC code: Name on Card: Billing Address: By signing this Agreement, and marking the box noted above, the undersigned does hereby agree that Family First Therapy, LLC and/or Kids Connect Occupational Therapy, LLC. has the right to charge to the above identified credit card and/or debit the account identified above any and all amounts that are owed. The undersigned agrees that its signature on this Agreement shall be deemed its signature on any sales charge receipt. Date: Print Name: Cardholder s Signature: 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 4

AUTHORIZATION TO PHOTOGRAPH AND VIDEOTAPE I/We (print name) give consent to photographs or videotaping of therapy sessions with (print child s name). I understand that visual media can be important learning and assessment tools and that the use of these media is an integral part therapy and continued learning. I hereby give my full consent for my child to be photographed, videotaped, and otherwise recorded on media during his/her during speech sessions with Family First Speech Therapy, L.L.C. and/or Kids Connect Occupational Therapy, LLC. Please check the box below to acknowledge your agreement Photography and Videotaping Policy: Authorization to Use Photographs and Recordings: I understand that Family First may use photos and videotapes as training and/or research tools. The use of videotapes for training may include any of the following: o o o o The viewing of videotapes during clinical supervision between Family First and/or Kids Connect and DIR Faculty members. The viewing of videotapes with family members for training purposes. The viewing of videotapes for training purposes with other professionals who are interested in the DIR model. The viewing of tapes during presentations when educating others about DIR /Floortime. I understand that the use of videotapes is an integral part of the clinical process. I further understand that no photograph or videotape will be released to the public or media without my express written consent. Child s Name Parent s Name Date Parent s Signature 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 5

Consent to Release Form I, (print name) give my permission and consent to Family First Speech Therapy, LLC. and/or Kids Connect Occupational Therapy, LLC. and respective contractors and employees to discuss and speak with school officials, teachers, psychiatrists, medical doctors, therapists, insurance representatives, and other professionals regarding my child as such may be needed in connection with the treatment and/or evaluation of such child. In addition, Family First Speech Therapy, LLC and/or Kids Connect Occupation Therapy, LLC. is authorized to receive any records, files, charts, and other documentation and information from such Third Party Professionals, and by signing this document, the undersigned is authorizing the release of any such information that may be held by a Third Party Professional to the Company. Any person who is provided a copy of this document may rely on it as the undersigned s full and unconditional consent to the release of any and all information pertaining to the child. The undersigned further authorizes Family First Speech Therapy, LLC and/or Kids Connect Occupational Therapy, LLC. to release any and all information pertaining to the treatment and/or evaluation of the child to any Third Party Professional that may in any way be involved in the treatment and/or evaluation of the child. The undersigned understands that some or all of the information obtained and/or released under this document may be protected under federal regulations including but not limited to HIPAA. By authorizing a release of information, \ the undersigned understands and agrees that they are agreeing to the release of such information notwithstanding the protections under HIPPA, provided, however, it is understood and agreed that Family First Speech Therapy, LLC. and/or Kids Connect Occupational Therapy, LLC. will maintain the confidentiality of any information obtained and will not disclose the same except as needed in the course of treating or evaluating the child. Child s Name Parent s Name Date Parent s Signature 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 6

Background and Contact Information Date: Name of Person Completing this Form: Relationship to child: Mother Father Stepmother Stepfather Legal Guardian Other: Child s Information (Required*) Child s Name: First Middle Last Date of Birth: Age: Sex: City of Birth: Hospital: Diagnosis (if any): Family Information Guardian #1: Mother Father Stepmother Stepfather Legal Guardian Other: Name: Address: Street City State Zip Code 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 7

Continued Home Phone: Business Phone: Cell Phone: Fax: Please circle the phone number above that is best to reach you at in an emergency E-mail address: Occupation: Marital Status: Single Married Separated Divorced Religious Preference: Guardian #2: Mother Father Stepmother Stepfather Legal Guardian Other: Name: Address: Street City State Zip Code Home Phone: Business Phone: Cell Phone: Fax: Please circle the phone number above that is best to reach you at in an emergency E-mail address: Occupation: Marital Status: Single Married Separated Divorced Religious Preference: Name and Ages of Child s Siblings Name: Name: Age: Age: 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 8

Continued Name: Name: Age: Age: **Medical Information** List any medications that your child takes on a regular basis. Please include any vitamins or nutritional supplements. Medication Reason for Medication List any allergies that your child has. Please include any symptoms to look out for and/or typical reaction. Allergy Symptoms/Typical Reaction Please list your child s doctor(s): (Required*) Pediatrician: Phone Number: NPI #: Fax Number: Diagnosis (es): Specialists (ex. Neurologist, Nutritionist, Allergist): During the pregnancy with this child, did the mother experience any unusual illnesses, conditions or accidents? No Yes 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 9

Continued Was the infant born before 37 weeks gestation? No Yes If Yes, how many weeks gestation? Were there complications during delivery? No Yes What was the child s birth weight? Did the baby have trouble breathing? No Yes Was the baby on a respirator? No Yes If Yes, how long? Did the baby have difficulty feeding? No Yes Did the baby have reflux? No Yes If Yes, please describe severity and treatment: Did the baby have seizures? No Yes Did the baby have other medical problems in the first year of life? No Yes 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 10

Please check the illnesses the child has had in the past. Also indicate the child s age at the last occurrence and note any hospitalization due to the illness: Illness Yes No Age Hospitalization Measles Chicken Pox Mumps Streptococcal (Strep) Throat Scarlet Fever Tonsillitis Ear Infection Seizures Meningitis Were any of these illnesses followed by noticeable changes in the child s typical behaviors? No Yes Has the child had any surgeries? No Yes Developmental Milestones When did your child first... Roll over Take first step Say first word Sit up Smile Combine two word phrases Crawl Babble Sleep through the night Stand alone Toilet train If your child is not toilet trained, please describe toileting behavior: 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 11

Does your child: Please mark any that apply. Choke or cough on foods or liquids? Currently puts toys or objects in his/her mouth? Brush or allow someone to brush his/her teeth? Gag? Repeat sounds, words or phrases over and over? Understand what you are saying? Retrieve or point to common objects upon request (ex. Ball, cup, shoes)? Follow simple instructions (ex. Shut the door, Get your shoes)? Respond correctly to yes/no questions? Respond correctly to who, what, where, when, why, how questions? Your child currently communicates using: Please mark any that apply. Body language (ex. Pointing or pulling you to what they want) Sounds (vowels or grunting) Words (ex. Up, kitty, shoe) 2 to 4 word sentences Sentences longer than four words Other: What is your primary reason for seeking therapy? Dental Does your child have any dental problems? No Yes Has your child had a dental exam? No Yes If Yes, date of last exam: Where was the child examined? Vision Does your child have any vision problems? No Yes 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 12

Does your child use glasses/contacts? No If Yes, when does your child use them? Yes Continued Has your child had a vision exam? No Yes If Yes, date of last exam: Where was the child examined? Hearing Does your child have any hearing problems? No Yes Does your child use a hearing aid? No If Yes, when does your child use it? Yes Does your child use other adaptive equipment? No If Yes, when does your child use it? Yes Has your child had a hearing test? No Yes If Yes, date of last exam: Where was the child examined? Feeding Does your child have any feeding issues? No Yes Has your child ever had a swallow study? No Yes If Yes, date of last exam: Where was the child examined? Developmental Evaluations: Has your child had the following evaluations? Psychological/Neuropsychological? No Yes If yes: Name of doctor Location of Evaluation Date 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 13

Please describe the results of the evaluation: Continued Occupational Therapy? No Yes If yes: Name of evaluator Place where evaluated Date Please describe the results of the evaluation: Physical Therapy? No Yes If yes: Name of evaluator Place where evaluated Date Please describe the results of the evaluation: Speech and language? No Yes If yes: Name of evaluator Place where evaluated Date Please describe the results of the evaluation: Developmental Evaluation? No Yes If yes: Name of evaluator Place where evaluated Date Please describe the results of the evaluation: Neurological Evaluation? No Yes If yes: Name of doctor Place where evaluated Date Please describe the results of the evaluation: 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 14

Continued Other evaluations? No Yes If yes: Name of evaluator Place where evaluated Date Please describe the results of the evaluation: Therapy Services Please list the therapy services that your child currently receives including number of hours per week: Type of therapy: Therapist: Address: Street City State Zip Code Phone number: Hours: Type of therapy: Therapist: Address: Street City State Zip Code Phone number: Hours: Type of therapy: Therapist: Address: Street City State Zip Code 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 15

Phone number: Hours: Additional Information Does your child understand English? Y N Does your child speak English? Y N Is there a language, other than English, spoken at home? Y N If so, which language(s): What language do the parents prefer to speak? What language does your child prefer to speak? Does your child currently attend another program? Y N If yes, where? What are your child s most enjoyable activities? What frightens your child? What do you do to comfort your child? What is your child s sleeping/napping schedule? Is your child aware of, or frustrated by, any communication difficulties? Is your child aware of, or frustrated by, any physical difficulties? Does you feel your child has sensory issues? Please describe: Does your child have any duties at home? Please describe: List the places that your child frequently visits: 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 16

Continued List the important people in your child s life and what s/he calls them: What do you see as your child s most difficult problem at home? Do you feel your child is developing at the same rate as his peers (socially, lay skills, self-help skills, etc.)? Play Skills: Please mark any that apply. Bangs items/head Mouths objects Stacks blocks Manipulates knob, buttons Pretends to sleep Feeds doll, stuffed animal, etc. Moves toy car with appropriate sound of vehicle Combines ideas (ex. Drives car and crashes it, feeds dog and puts it to bed) Plays out scenarios, 3-4 steps (ex. Sets table, pretends to cook food, eats food) School History Name of the school your child currently attends: Teacher s name: Grade: Has your child repeated a grade? No Yes If Yes, what grade? What are your child s strengths and/or best subjects? What is your child s most difficult problem in school? Behavior Characteristics: Please mark any that apply. Cooperative Willing to try new activities Attentive Spends nights away from home 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 17

Plays alone for minutes at a time Destructive Separation difficulties Aggressive Picky eater Withdrawn Easily frustrated Attends summer camp Impulsive Participates in family trips Uses language fluently Cares for pets Stubborn Short attention span/easily distracted Restless Attends religious/spiritual gatherings Poor eye contact Inappropriate behaviors: Self-abusive behaviors: Has nervous tendencies (ex. Unusual fears, temper tantrums, extreme moods). Please describe: Please describe a typical 24 hour time period for your child (i.e. - from the time they wake up, until they go to bed including daily routines and how well they do or do not sleep.) Please describe your vision for your child's individual educational and emotional needs: (Required*) 805 Rhode Place #350 Houston, TX 77019 P: 713-522-8880 F: 713-522-8881 Page 18