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( mm / dd / yyyy )











MEDICAL HISTORY Any problems with birth/delivery?







Has your child ever seen a speech therapist before


Is there a family history of speech or language difficulties?

Did you experience any difficulties with feeding?


Has your child ever been evaluated or is currently seeking treatment from an occupational therapist, physical therapist, behavior therapist, psychologist, nutritionist, or dietitian?




Cancellations – non emergency:

Except for emergency situations, all appointments must be cancelled at least 24 hours in advance by calling or emailing your therapist. We consider the following to be examples of NON EMERGENCY reasons to cancel an appointment: vacations, prescheduled doctor appointments, family events, parties, recreational events, after school activities, lack of babysitter, car trouble, traffic, holiday weekend, school holiday, day before or after a holiday, schedule conflict, and sibling illness.

All appointments that are not cancelled at least 24 hours in advance of the scheduled appointment will be charged a late cancellation fee of $55. This fee is not covered by insurance or other third party payer and must be paid in full no later than your next appointment. Patient will not be seen if late cancellation fee has not been paid.
Initial.

Cancellations – emergency: In case of emergency (sudden illness, death in family, hospitalization, emergency doctor visit), appointment must be cancelled as early as possible prior to appointment time. There is no charge for an emergency related cancelled appointment.
Initial.

No Show without Notification: All appointments that are missed without notification will be charged $75 for the missed appointment. This fee is not covered by insurance or other third party payer and must be paid in full no later than your next appointment. Patient will not be seen if late cancellation fee has not been paid.
Initial.

Attendance:

Speech, language, and feeding therapy will not be effective unless it is consistent and regular. Therefore, regular attendance at all appointments is important. If two or more appointments within a four week period are missed and not rescheduled, we will not be able to hold the appointment time and it will be given to another person. In that case, we will place you on our waiting list for therapy. If the regular appointment time is difficult to maintain, please discuss the possibility of a different time or day with your therapist
Initial.






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CONSENT TO COMPLY WITH FEDERAL HIPAA ACT

Patient Consent for Use and Disclosure of Protected Health Information With my consent and signature, Speak Live Play Inc. may use and disclose protected health information about me or my child to:
1. Carry out treatment, payment, and healthcare operations (services)

2. Call my home or other designated locations and leave a message on voicemail in reference to any items (i.e. appointment reminders, insurance items, references to clinical care of laboratory results, etc.) that will assist in the practice of medical care for me or my child.

3. Mail to my home or other designated address any item (i.e. appointment reminder cards, patient financial statements, etc.) that will assist in practice of medical care form me or my child. Such correspondence is to be marked personal and confidential.

4. Send or transmit email to any location provided by me for all above similar items and purposes.

5. To use and/or disclose protected health information about me or my child to/with third parties involved in mine or my child’s care. Such parties may include, but are not limited to, insurance companies, hospitals, specialty physicians, and public school educators, I may specifically describe the type of information (i.e. dates of services, level of detail, origin of information, etc.) subject to disclosure and may revoke this permission at a time and date chosen by me. By providing a written statement to the privacy office of the Speak Live Play Inc., I may revoke this permission; however, the Speak Live Play Inc. may decline to provide further treatment to me or my child. Speak Live Play Inc. may also decline further treatment to me or my child should my restrictions on the type of third party information, in the center’s opinion, impede medical care of me or my child.

I have the right to request that the Speak Live Play Inc restrict how it uses or discloses mine or my child’s health information. However, as state previously, the Speak Live Play Inc. is not required to agree to my restrictions. If the Speak Live Play Inc accepts my restrictions, the Speak Live Play Inc is then bound by the restriction in the agreement, setting forth the restricted information until providing me, in writing, a cessation of such agreement.

I may revoke this entire consent, in writing, at any time. If I do not sign this consent, or revoke this consent, the Speak Live Play Inc, in their sole discretion, may decline further treatment for me or my child.