Milestones Speech Intake Form Logo
  • Milestones Speech/Language Intake Form

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  • Pregnancy and Birth History

  • Medical History:

  • Speech and Language Development

  • List approximate age the child achieved the following developmental milestones: Said first words: . Put 2+ words together: .   Babbled:   Toilet trained:      


  • Play/Social Skills

  • Education:

  • Policies and Service Agreements

  • ATTENDANCE POLICY

    All parties reserve the right to cancel sessions due to holidays, illness, and emergencies. We will always inform you at least 24 hours ahead of time if we need to cancel or reschedule a session(s) unless there are precluding limitations to doing so. We recognize all national holidays and do not provide make-up sessions for sessions missed on these days. We expect that if you need to cancel or reschedule your child’s session, that you call/text/email us as soon as you are aware of the change. If we do not receive a 24-hour notification of your cancellation or you fail to show up for an appointment, then you will be charged for the full total of appointment with the fees described herein, as well as place your child’s services at risk for termination. No Call-No Show is defined as the parent failing to inform Milestones Provider or Front Office via email, text or phone call/message that he or she will be late or cancelling with 24 hours notice. Emergency situations are handled on a case by case basis. For late arrivals, our therapists will not be available to perform sessions once 15 minutes of the scheduled time has passed without the child arriving for therapy and the family will be charged the full session amount.For late pickups, we do not have staff available to look after your child after their scheduled pick-up time has passed. You must pick your child up on time. Two late pick-ups will result in termination of services. We cannot provide your child therapy if he/she is or has been ill or has had a fever of 100.00 or above and until he/she is fever/symptom free for 24 hours. You must inform Milestones of your child’s wellness status within 24 hours of the scheduled session time in order to refrain from accumulating a No-Call/No-Show.*****Additionally, if your child misses 20% or more of his or her scheduled sessions in a given month without a Doctor’s excuse(s), services will be terminated.******Our policies are designed to protect the integrity of your child’s treatment program. They will be strictly enforced.Our contact information is:205-253-6903 You may call and/or text us at this numbertherapy@milestonesaba.comOr you may text/email your Therapist directly
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  • Payment Agreement: Patient Copayment and Deductible Agreement

    This Agreement is made effective on the date of signature, between Milestones Behavior Group, INC , located at 1280 Columbiana Road Suite 150, Birmingham, AL 35216 ("Provider") and the Patient. Patient agrees to pay all copayments and deductibles associated with healthcare services received from Provider. These services may include but are not limited to medical consultations, examinations, treatments, procedures, and any other services deemed necessary by Provider for Patient's healthcare needs.Copayments:Patient acknowledges that certain healthcare services may require copayments, which are predetermined fees set by Patient's insurance provider. Patient agrees to pay the applicable copayment at the time services are rendered, as outlined by Patient's insurance plan.Deductibles:Patient understands that deductibles are predetermined amounts set by Patient's insurance provider, which Patient must pay out-of-pocket before the insurance plan begins to cover certain healthcare expenses. Patient agrees to pay any deductibles associated with services received from Provider before insurance benefits are applied.Billing and Payment:Patient agrees to provide accurate insurance information to Provider and authorize Provider to bill Patient's insurance company for covered services. Patient understands that copayments and deductibles are Patient's responsibility and agrees to pay any outstanding balances not covered by insurance within the timeframe specified by Provider.Insurance Coverage:Patient acknowledges that insurance coverage and benefits are determined by Patient's insurance policy and may vary depending on the services received. Patient agrees to familiarize themselves with their insurance policy and to contact their insurance provider directly with any questions regarding coverage or benefits.Non-Covered Services:Patient acknowledges that certain services may not be covered by Patient's insurance plan, and Patient agrees to pay for any non-covered services in full at the time services are rendered.Financial Responsibility:Patient understands and agrees that they are financially responsible for all copayments, deductibles, and any other fees associated with healthcare services received from Provider, regardless of insurance coverage or benefit limitations.Agreement Termination:This Agreement shall remain in effect until terminated by either party upon written notice to the other party.Governing Law:This Agreement shall be governed by and construed in accordance with the laws of Alabama/Jefferson County.
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  • Private Pay Rates

    Speech & Language evaluation: $250 Flat Rate. Ongoing Speech Therapy Sessions: $80 per session
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