FUNDAMENTAL THERAPY SOLUTIONS

New Patient Intake Form

Services Seeking

Speech & Language

Occupational 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 #:

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

Back Image

Insurance Card Front Image

Front 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 "yes", which Faculty?

Has your child received therapy services elsewhere in the last year? If "yes", which Faculty?

** If your child has received a 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

Who is your mobile phone provider?

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

Email Reminder

Text reminder

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

Signature Below:

Clear

Authorization For Release Of Patient Information

I hearby authorize FTS to disclose my child's health information to my child's primary care physician. (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

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

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.

I do not authorize clinicians at Fundamental Therapy Solutions to Photograph and/or video record my child 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.

Please list any medications taken during pregnancy. *

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 HOW LONG.

What feeding method was used after birth?

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

Yes

Developmental Milestones

Please indicate in months or years the approximate age, (or N/A if not age appropriate at this time) that your child achieved the following Milestones. If you are unable to recall the approximate age that your child achieved a milestone, please indicate whether or not you feel it was "On time" or "Late/Delayed". If there are any additional concerns regarding these milestones, please note them.

Grasp crayon/pencil *

Sat without support *

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):

When was your child's most recent hearing test/screening? *

Results of most recent hearing test: *

Does your child currently have a known hearing impairment? If yes, what is the severity? *

Yes

If yes, what is the severity?

My child has had several ear infections.

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

I suspect my child has a hearing problem.

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

When were tubes put in your child's ears? *

Does your child wear hearing aids? If yes, what type, and for how long? *

When was your child's most recent vision test/screening?

Results of most recent vision test

Does your child require the use of glasses/corrective lenses?

Please list any medical precautions (Fall risks, Seizures, etc.):

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).

School Information

*Note: If your child does not go to school, please just answer question one.

If your child does NOT attend a school/preschool and stays home, who does he/she stay home with?

Child's school/preschool/daycare:

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

Does your child recieve Speech/Language, Occupational Therapy services at school? *

Has your child ever repeated a grade? If so, what grade? *

Has your child ever been suspended, expelled, or had significant disciplinary consequences for negative behavior? If yes, please explain. *

What are your child's academic strengths? *

List any areas in which your child is struggling: *

Have academic tutoring services been sought? If yes, please explain which subject(s), who the provider was, and for how long. *

How does your child primarily communicate with you/others?

What percentage of your child's speech do you understand?

Does your child........

Understand most of what people say? *

Consistently respond correctly to "Yes" and "No" questions? *

Often repeat the last thing that you said or engage in excessive repitition of words/sentances heard previously? *

Appropriately label objects in his/her environment? *

Appear to read body language (including facial expressions) appropriately for his/her age? *

Consistently follow directions? (For younger children, do they consistently retrieve or point to common objects- i.e ball, shoe, eup, etc. upon request? *