FUNDAMENTAL THERAPY SOLUTIONS

New Patient Intake Form

Services Seeking

Speech & Language

Occupational Therapy

Physical Therapy

How did you hear about FTS?

What are your primary concerns for your child?

Primary Language spoken at home? If there is a secondary, please list as well. *

Parent/Guardian 1 D.O.B:

Relationship to child

Parent 1 STREET Address (Ex. 100 NW 47th Ave)

Parent/Guardian 1 Social Security #

Parent/Guardian 1 Phone Number

Parent/Guardian 2 D.O.B

Relationship to child

Parent 2 STREET Address (Ex. 100 NW 47th Ave)

Parent/Guardian 2 Social Security # (REQUIRED!!):

Parent/Guardian 2 Phone Number:

Insurance Information

Do you have private or sooner care insurance?

Private Insurance

Sooner Care

Medical Insurance Provider

Insurance Card Back Image

Front Image

Insurance Card Front Image

Back Image

If you have multiple insurance policies, as well as Soonercare coverage, please list ALL insurances here

Has your child received therapy services elsewhere in the last year?

Yes

** If your child has received a Physical Therapy, Occupational Therapy, Speech Therapy, or Feeding Therapy Evaluation, please call your previous therapy clinic to have them fax over your child's current evaluation/s and progress notes. Fax Number: 1-539-430-0051

Appointment Reminder Consent

How would you like your appointment reminders? (PLEASE CHECK ONE)

Email Reminder

Text reminder

Who is your mobile phone provider?

Authorization For Release Of Patient Information

I hearby authorize ____________ to disclose my child's health information. (Please list a physician/facility name if applicable)

Please select from the following items that may be released to the physician/facility listed above: (If applicable)

Facility ReIease: I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand that authorization will expire by law, 180 from the date of signature unless I otherwise specified. I understand that I may revoke this authorization by contacting Megan Atterberry at FTS. The revocation must be in writing.

Clear

Authorization for communication of patient information between School and FTS

Do you authorize FTS to communicate with your child's school and/or teachers regarding assessments and progress (if applicable)?

If yes, please list the school name:

Please select from the following items that may be released to the school listed above:(If applicable)

Current classroom performance and/or behavior

Educational or Therapeutic progress

Speech/Language evaluations, reports, & recommendations

Occupational evaluations, reports, & recommendations

Physical Therapy evaluations, reports, & recommendations

School Release: I understand that this authorization is voluntary and I may refuse tosign this authorization. I understand that authorization will expire by law, 180 from thedate of signature unless I otherwise specifiy. I understand that I may revoke thisauthorization by contacting Megan Atterberry at FTS. The revocation must be in writing.

Please sign below *

Clear

Authorization For Communication

Person 1 Phone Number

Relationship to patient

This person 1 is authorized to (Select all that apply)

Speak freely with my child's therapist(s) regarding daily progress

Observe therapy sessions

Be given reports to be transported to parent/guardian

Transport patient to and from sessions

None of the above

Person 2 Phone Number:

Relationship to patient:

This person is authorized to (Select all that apply)

Speak freely with my child's therapist(s) regarding daily progress

Observe therapy sessions

Be given reports to be transported to parent/guardian

Transport patient to and from sessions

None of the above

Who is your phone carrier?

Authorization to Photograph/Video Record

By signing below, I authorize clinicians at Fundamental Therapy Solutions to

Photograph and/or video record my child for promotional purposes.

Use these photos/videos on the website for promotional purposes.

Therapists may text these photographs and/or videos via a secured medium to this phone number:

Therapists may email these photographs and/or videos via a secured medium to the following email address:

I understand that this authorization may be used on social media, website, promotional materials and/or posted in our clinic.

I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand this authorization will expire, by law, 180 days from the date of this authorization unless I otherwise specify.

I understand that I may revoke this authorization by contacting Fundamental Therapy Solutions. The revocation must be in writing.

Parent/Guardian (print) *

Relationship to Patient *

Parent/Guardian Signature *

Clear

Attendance Policy Agreement

Patients may be dropped off for sessions with the understanding that parents/guardians must return at least 5 minutes prior to the end of session.

Please Sign Below *

Clear

Financial Agreement

Financial Agreement is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are bound to abide by such restrictions. I have been provided a copy of the FTS privacy practices and have been given a chance to read it and ask questions.

Please Sign Below *

Clear

Consent for Student Observers

I consent to student observers being present during my child's therapy session. I understand that my child's primary therapist will be present and the student observer is only in the room for observation purposes.

Yes

I gave consent that my child can interact with other children and therapist/s when in therapy session.

Yes, I give consent

No, I do not give consent

I give consent that my child can see another therapist if my child's therapist is unavailable or absent.

Yes, I give consent

No, I do not consent

Caregiver/Parent Signature

Clear

Child lives with (Select all that apply)

Does anyone in the family have a history of Speech, Language, Hearing, Balance, Reading, or Mobility problems? If yes, please explain.

Prenatal, Birth & Neonatal History

Were there any problems during pregnancy? If yes, please describe.

Child's Birth Weight (___ lbs. ___oz.)

Delivery

Vaginal

C-Section

Was your child born prematurely? If yes, please answer the next question as well.

Yes

Child's gestational age (i.e. 34 weeks)

Describe any difficulties at the time of birth

Was there a prolonged hospital stay after birth? If yes, please describe WHY and HOWLONG.

What feeding method was used after birth?

Were there any feeding difficulties? If yes, please describe.

Yes

Please list any medical diagnoses your child has along with the date of the diagnosis(e.g. ADHD, OCD, Seizures, Asthma, Autism). *

Please list any medication your child takes regularly. *

Does your child have any allergies (food, latex, etc.) If yes, please explain. *

Has your child ever had prolonged problems with (Select all that apply):

My child has had at least one ear infection which lasted more than 3 months.

Yes

My child has had several ear infections.

Yes

I suspect my child has a hearing problem.

yes

My child has had tubes in his/her ears? If yes, please refer to next question as well.

Yes

Does your child require the use of any special equipment (e.g. Wheelchair, Leg braces)? If yes, please specify.

Please list any surgical history along with the date of surgery (e.g. Tonsillectomy, Adenoidectomy, etc).

Does your child currently have an Individualized Education Plan (IEP)?