Fillable Developmental Pediatric Intake CCT Revised 20.08.21

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Developmental Pediatric Intake CCT Revised 20.08.21

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Patient Information Form
Patient Information
Last Name:
First Name:
MI:
SSN:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth:
Gender:
Marital Status:
Email:
Emergency Contact
Last Name:
First Name:
Relationship:
Phone:
Employer
Name:
Phone:
Address:
City:
State:
Zip:
Problem
Problem Description:
Date of Injury:
Motor Vehicle Accident:
Y
N
State Accident Occurred:
Referred By:
Last Physician Visit:
/ /
Latest Referral Information:
Latest Plan of Care:
Notes:
Primary Insurance
Insurance:
ID:
Group #:
Deductible:
Coinsurance:
Copay:
Max Benefit:
Secondary Insurance
Insurance:
ID:
Group #:
Deductible:
Coinsurance:
Copay:
Max Benefit:
Tertiary Insurance
Insurance:
ID:
Group #:
Deductible:
Coinsurance:
Copay:
Max Benefit:
I authorize release of information requested by my insurance plan for payment.
I understand that I am financially responsible for any balance due.
Signature:
Date:
/ /
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Patient Acknowledgement and Consent
Financial Policy Your billing will be prepared and managed by MOTION PT Group as a Cypress Creek Therapy provider. All billing statements for
services received at this location will come to you from Cypress Creek Therapy. Please make all checks payable to Cypress Creek Therapy.
PATIENT FINANCIAL RESPONSIBILITY: MOTION PT Group is contracted with many insurance companies. All bills for your outpatient rehabilitation therapy
services will be submitted by Cypress Creek Therapy directly to your insurance carrier. By signature below, you authorize payment of medical benefits
directly to Cypress Creek Therapy and understand you are responsible for payments of all services rendered in the event any third party does not
pay. If you belong to an HMO/ Managed Care Organization that Cypress Creek Therapy participates with, you agree to be responsible for securing
necessary referrals and making direct payments as required by your plan. As a courtesy, will submit to insurance for physical, occupational and/or
speech therapy authorizations. Medicare patients participating in the Telehealth program – please be advised that physical therapy is not a covered
Medicare service as part of the Telehealth program. Patients will be responsible for payment at the time of service or will be billed for services in full
at a later date. By signature below, you acknowledge understanding of responsibility for payment of all services rendered.
Agree: ________________________________________________ (patient signature)
CO-PAYMENTS, DEDUCTIBLES and FEES: Cypress Creek Therapy is legally and contractually required to comply with the payment policies set forth by each
insurance plan. As a result, Cypress Creek Therapy will not uniformly waive co-payments and/or deductibles. Copayments must be paid in full before
each treatment session. If you choose to issue your co-payments on a weekly basis, payment is due prior to your first treatment session of the week.
If you wish to cancel or reschedule an appointment, we require a minimum of 24-hour advance notice. Less than 24-hour notice may result in a $25
cancellation fee. If you have frequent cancellations or fail to keep two appointments without notice, you may be discharged from the program.
Applicable cancellation fees may be charged to your patient account. If you are experiencing financial hardship, you may qualify for financial
assistance with the cost of your services. Please ask to speak to a member of the Cypress Creek Therapy Patient Accounts Department. In the event
it becomes necessary to refer your account for collection, you will be held responsible for the attorney fees and collection costs.
Agree: ________________________________________________ (patient signature)
CONSENT FOR TREATMENT AND CARE FOR ADULT PATIENT: By signature below, you agree and give consent to receive outpatient rehabilitation
therapy services through Cypress Creek Therapy and its contracted provider MOTION PT Group and as such consent to receive rehabilitative treatment as
considered necessary and proper by the treating therapist(s) in treating my physical condition. No guarantees have been made regarding the
projected outcome of care. I understand I have the opportunity and am encouraged to ask questions about my care and treatment.
Agree: ________________________________________________ (patient signature)
TREATMENT OF MINOR: By signature below, I agree and give consent as either parent or legal guardian for my minor child who is under the age of 18
(“Minor”) to receive outpatient rehabilitation therapy services through Cypress Creek Therapy and its contracted provider and as such grant consent for Minor
to receive rehabilitative treatment as considered necessary and proper by the treating therapist(s) in treating Minor’s physical condition. No
guarantees have been made regarding the projected outcome of care. I understand that as parent or legal guardian I have the opportunity and am
encouraged to ask questions about Minor’s care and treatment. I further understand that as parent or legal guardian of Minor, I must accompany
Minor to his/her Initial Evaluation. I further understand that as parent or legal guardian of a Minor under the age of 12, I must be present during all
care or treatment rendered to Minor. As parent or legal guardian, I am not required to attend follow up treatment sessions if Minor is 12 years or
older, provided that the “Consent to Treat a Minor” document has been completed.
Agree: ________________________________________________ (patient or legal guardian signature)
DISCLOSURE TO INDIVIDUALS: I acknowledge I have been offered a copy of Cypress Creek Therapy’s HIPAA Notice of Privacy Practices. I authorize
Cypress Creek Therapy to use and/ or disclose my Protected Health information (“PHI”) to carry out and arrange for my treatment, seek and receive
payments for my treatments, and carry out business operations of the office in accordance with the permitted disclosures under HIPAA. I give
permission to Cypress Creek Therapy and its contracted provider MOTION PT Group and/or their authorized representatives to communicate medical
information to me via any or all of the following methods as checked below:
☐ Voicemail: Phone # ☐ Fax: #
☐ Email: Email address: ☐ Writing
I give permission to Cypress Creek Therapy and MOTION PT Group providers and/or their authorized representatives to discuss my
personal healthcare information only with the following individual(s) whom I have listed below:
Name: Relationship to Patient
1.
2.
Agree: ________________________________________________ (patient signature)
MOTOR VEHICLE/NO FAULT/WORKERS’COMPENSATION: If I have been involved in a motor vehicle accident or a workers compensation injury, I
agree it is my obligation to disclose that to Cypress Creek Therapy and its contracted provider MOTION Sports Medicine. I understand and agree that
I must complete and submit No Fault application to my carrier within 30 days of accident date (or other period as determined by my carrier or
applicable law) and comply with any Independent Medical Examination (IME) requests. If I fail to do so, I understand and agree that I will be held
responsible for all payments until the time of settlement, judgment, or payment by attorney or the automobile insurance company. If I sustained an
injury on the job and are receiving Physical, Occupational and/or Speech Therapy under Worker’s Compensation I understand and agree that I will
comply with all requests set forth by Worker’s Compensation laws and carriers
Agree: ________________________________________________ (patient signature)
I have read this Patient Acknowledgement and Consent. I hereby agree to receive treatment and physical, occupational and/or speech therapy
services in accordance with the above stated terms.
Patient Signature: Printed Name: Date:
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Patient Cancellation/Missed Appointment Policy and Acknowledgement
MOTION strives to provide our patients with the utmost professionalism and excellence of service. Our
commitment to your well-being and improvement of your physical abilities is something everyone in our
clinic takes seriously.
Because we care about you and your progress in therapy, we emphasize the importance of patient
commitment to the care you receive at MOTION owned, operated and/or managed clinics. Scheduling
is based on numerous factors, including patient need, staff availability and physician orders. Your
dedication to the recommended number of treatments is a vital component of your progress; therefore,
we have certain requirements that should be followed in order to ensure optimum results.
We expect all patients to keep all scheduled appointments or to provide adequate 24 hour notice of
intent to cancel and reschedule an appointment. If you need to cancel and reschedule an appointment,
please provide us with greater than 24 hours’ notice. To maintain your therapy schedule and ensure
optimal results of your therapy, your make-up appointment should be the same week, preferably the
day following your original appointment.
In cases of two occurrences of non-compliance with your scheduled visits, in accordance with
applicable law, you will be charged a cancellation fee of Twenty Five Dollars ($25.00) which will be
solely your responsibility (i.e. no third party will be charged a cancellation fee). Further, we reserve the
right to discontinue your care with a reasonable amount of notice to you so that you may locate another
therapist to continue your care or discontinue your privilege to schedule appointments in advance
allowing only same day scheduling when available. We will also inform your physician that your service
has been discontinued due to non-compliance with the prescribed rehabilitation order should we follow
that course.
PLEASE PROVIDE AT LEAST 24 HOURS NOTICE FOR CANCELLATION OR FOR
RESCHEDULING AN APPOINTMENT. APPOINTMENTS CANCELLED WITHOUT 24 HOURS
NOTICE WILL RESULT IN A $25.00 CANCELLATION FEE.
We value your patronage and strive to accomplish optimal results and success for you
I HAVE READ AND UNDERSTAND THE ABOVE POLICY AND AGREE TO ADHERE TO THE
POLICY
Signature
Date
Printed Name
Therapist Signature:
1 | P a g e
Date:
DEVELOPMENTAL PEDIATRIC INTAKE FORM
PATIENT INFORMATION
Patient Name:
Parent / Guardian Name:
Relationship to Patient:
Pediatrician:
Referring MD:
Birth History
Date of Birth:
/ /
Age:
Type of Delivery:
Vaginal
Caesarean
Complications?
Yes
No
If yes, please explain
Premature Birth?
Yes
No
If yes, please explain
NICU?
Yes
No
If yes, please explain
MEDICAL HISTORY
Primary Medical Condition Requiring Rehabilitation
When did the problem begin
/
Briefly describe the reason for your visit
Are you/your child under the care of another Physical / Occupational / Speech Therapist for this
condition?
Yes
No
Please list any significant medical / surgical history
Please list any hospitalizations
Have you/your child received Physical / Occupational / Speech Therapy
for this condition in the past (if yes, explain below)
for a previous condition (if yes, explain below)
Have you/your child seen a specialist (physician, psychologist, special education teacher, etc.)
for this condition in the past (if yes, explain below)
for a previous condition (if yes, explain below)
Therapist Signature:
2 | P a g e
Date:
Please indicate approximate age of onset or date for the following:
Illness / Diagnosis
~ Age of Onset / Date
Illness / Diagnosis
~ Age of Onset / Date
Allergies
Feeding Tube
Apraxia of Speech
German Measles
Asthma
Headaches
ADHD
Hearing Loss
Autism
High Fever
Cerebral Palsy
Influenza
Chicken Pox
Mastoiditis
Cleft Palate / Lip
Measles
Colds
Meningitis
Convulsions
Mumps
Croup
Pneumonia
Dizziness
PE Tubes
Down Syndrome
Reflux
Draining Ear
Sinusitis
Dyslexia
Stuttering
Ear Infections
Tinnitus
Encephalitis
Tonsillitis
Epilepsy / Seizures
Vision Problems
Other(s):
Genetic Abnormalities:
Learning Disabilities:
Is there a history of speech, language or hearing impairments in your family? (if yes, describe below)
Yes
No
Does your child use any of the following devices? If yes, please note device type and wearing schedule below
Orthotics
Braces
Splints
Augmentative and Alternative Communication Devices
MEDICATION INFORMATION
Please list ALL medication, vitamins, herbals and dietary supplements you/your child are currently taking
MEDICATION
(prescription, over-the-counter,
vitamins, herbals, dietary supplements)
DOSAGE
FREQUENCY
(times per day)
ROUTE
(oral, injection,
transdermal, inhale)
REASON FOR MEDICATION
Therapist Signature:
3 | P a g e
Date:
SPECIAL TEST
Test Performed
Date
Result
X-Ray
CAT Scan
MRI
Bone Scan
Video Fluoroscopic Swallow Study (VFSS)
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Other: ______________________________________
PAIN
Do you/your child have persistent or frequent pain? (if yes, complete below)
Yes
No
Location on body
Pain at WORST
Circle One
0
1
2
3
4
5
6
7
8
9
10
Mild
Moderate
Severe
NO PAIN
WORST PAIN
Pain at BEST
Circle One
0
1
2
3
4
5
6
7
8
9
10
Mild
Moderate
Severe
NO PAIN
WORST PAIN
Therapist Signature:
4 | P a g e
Date:
Pain on AVERAGE
Circle One
0
1
2
3
4
5
6
7
8
9
10
Mild
Moderate
Severe
NO PAIN
WORST PAIN
Does pain awake you/your child at night?
Yes
No
Does pain affect your/your child’s daily activities? (if yes, complete below)
Yes
No
Please circle all symptoms that apply
Aching
Burning
Numbness
Tingling
Throbbing
Spasms
Tightness
Dull Pain
Sharp Pain
Other:
ALLERGIES
Please indicate your/your child’s allergies and allergic reactions if applicable
Allergic to
Reaction
Tape
Latex
Food (specify)
Other:
SOCIAL HISTORY
Home Status
Child lives with
Both Parents
Mother
Grandparents
Father
Other:
Do you/your child live with siblings and/or other children? (if yes, complete below)
Yes
No
Name:
Relationship:
Age:
Name:
Relationship:
Age:
Name:
Relationship:
Age:
What is the primary language spoken at home?
If multilingual, please note additional languages:
Are there steps to enter your/your child’s building / home or within the home? (if yes, complete below)
Yes
No
Number of steps to enter
Number of steps within
Therapist Signature:
5 | P a g e
Date:
List your/your child’s three major FUNCTIONAL difficulties / problems
(e.g. self-care, household chores, changing positions, shopping, transportation, walking, communicates wants & needs)
1.
2.
3.
List your/your child’s three major SYMPTOM complaints
1.
2.
3.
List your/your child’s SPECIFIC GOALS for rehabilitation
1.
2.
3.
Therapist Signature:
6 | P a g e
Date:
PARENT / GUARDIAN TO COMPLETE FOR MINOR
DEVELOPMENTAL HISTORY
Milestone
Age Achieved
Rolling
Sitting
Crawling (hands & knees)
Walking
Use of single words (e.g. no, mom, dad, doggy, etc.)
Talking
Use simple questions (e.g. where’s doggy?, etc.)
Engage in conversation
Self-feed
Eating puree
Eating solid foods
Self-dress
Use of toilet
Does your child exhibit any undesirable behavior(s)? (if yes, complete below)
Yes
No
Please note behavior trigger(s), and method(s) used to regulate / modulate / calm child’s behavior
Behavior
Trigger
Intervention
Does your child exhibit frustration when he/she is not understood? (if yes, describe below)
Yes
No
Does your child experience difficulty with gross motor (large muscle coordination) activities?
(e.g. walking, running, kicking, jumping, catching)
Yes
No
Does your child experience difficulty with fine motor (small muscle coordination) activities?
(e.g. pinching, buttoning, writing, eating)
Yes
No
Has your child received a hearing screening / evaluation by an audiologist or other professional? (if
yes, explain below)
Yes
No
Has your child received a vision screening / evaluation by a developmental optometrist or other
professional? (if yes, explain below)
Yes
No
Has your child received Vision Therapy? (if yes, explain below)
Yes
No
Results
Was your child breast fed (if yes, what age was child weaned)
Yes
No
Was your child bottle fed? (if yes, complete below)
Yes
No
Beginning Age
To Present
Weaned Age
Therapist Signature:
7 | P a g e
Date:
Does your child have a history of feeding problems? (e.g. sucking, drooling, swallowing, chewing, etc.)
Yes
No
Is your child on a special diet, e.g. gluten-free, casein-free, etc.? (if yes, describe below)
Yes
No
Does your child eat liquid?
Yes
No
Does your child eat solid foods? (if yes, check all that applies below)
Yes
No
Puree (apple sauce, stage baby food)
Crunchy Solid (crackers, chips)
Soft Solid (banana, bread)
Is your child nonverbal?
(if yes, describe how your child communicates with others / type of communication device used)
Yes
No
Please circle method(s) of communication your child displays
Gestures
Single Words
Short Phrases
Sentences
Sign Language
Augmentative Communication Device
Other:
Please indicate your child’s response to sound
Responds to all sounds
Does not respond to sounds
Responds inconsistently to sounds
Other:
Please describe how your child participates in the following activities
Dressing
Feeding
Bathing
Sleeping
Does your child participate in physical activities? (if yes, describe; e.g. exercise, sports)
Yes
No
Does your child have opportunities to interact / play with peers? (if yes, describe)
Yes
No
Please describe activities your child likes / dislikes
Likes
Dislikes
School Information
Is your child currently attending school? (if yes, complete below)
Yes
No
School:
Grade:
How is your child performing academically or pre-academically?
Therapist Signature:
8 | P a g e
Date:
Does your child interact or engage with peers at school? (if no, explain below)
Yes
No
Does your child receive special services at school, e.g. 504 plan? (if yes, specify below)
Yes
No
Is your child enrolled in Special Education services? (if yes, complete below)
Yes
No
Has an Individualized Education Plan (IEP) been developed? (if yes, complete below)
Yes
No
List the primary IEP goals:
Please note additional comments that may facilitate therapist interaction with your child during treatment:
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Developmental Pediatric Intake CCT Revised 20.08.21

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Completed 22 April 2021

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