Pediatric Patient Intake Form - SpeechFamily  Logo
  • WELCOME TO SPEECHFAMILY!

  • Thank you for choosing SpeechFamily to help you or your loved one reach their speech and language goals. We realize that you have options regarding speech therapy and we are happy you selected us. 

    This form will take approximately 10 minutes to complete. Several consent and policy forms within the intake will require your E-Signature. Please do not print these forms. Please fill them out online 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records. All information is Confidential.

    Additionally, if you or your loved one has had any recent assessments completed by other health care professionals, including but not limited to a Neuropsychologist, Audiologist, ENT, etc., please provide copies so that we are able to get the whole picture. 

    We look forward to seeing with you! 


    Sincerely, 

    _____________________________________

    Jennifer Bowen, M.S., CCC-SLP

    Licensed Speech-Language Pathologist 

    Founder of SpeechFamily 

     

      

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  • Cancelation Policy:

  • Please mark the date of your Appointment on your calendar. While we make every effort to remind our clients of appointments by email and phone two or more days prior to the appointment, it is the client's responsibility to maintain his or her schedule. Missed appointments will be invoiced at full cost. Extenuating circumstances will be reviewed on a case-by-case basis. A strict twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation. If non-emergency cancellations become excessive, the client may lose his or her weekly slot in the clinician's schedule.

     

     

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  • Current Fee Schedule and Payment Policy:

  • Thank you for choosing SpeechFamily for speech and language therapy. The following is the current Fee Schedule and Payment Policy for services to be provided to the client by Jenny Bowen, M.S., CCC-SLP and Speech Language Therapist employeed at SpeechFamily, LLC.  Please understand that SpeechFamily, LLC reserves the right to change and/or modify the fees set forth below, but you will receive thirty (30) days advanced notice of any increase in such fees. 

    Please note that SpeechFamily, LLC is a private pay only practice at this time and DOES NOT accept insurance. We will however provide documentation when requested for reimbursement by your insurance. Clients are responsible for
    confirming insurance coverage and handling all reimbursement. Please note that all insurance companies vary and speech/­language therapy services (CPT CODE 92507) may or may not be a covered benefit by your insurance.

    All payment for services is required at the time services are rendered. We accept payment by cash, personal check, or credit card (HSA, FSA, Visa, MasterCard, American Express, Discover). 

    FEE SCHEDULE 

    EVALUATION

    • Comprehensive Speech and Language Evaluation:formal testing, scoring, and interpretation, report writing, consultation with teacher or family $750
    • Oral-motor/articulation comprehensive, formal evaluation only (any age) with report: $450

    THERAPY

    • AT DUNWOODY STUDIO:
      • 60 minute Speech and Language Therapy Session $180 per hour
      • Weekly Social Group $180 per hour
      • Summer Camp $525 per week
    • IN HOME/SCHOOL:
      • 60 minute Speech and Language Therapy Session $180 per session + $30 travel fee $210

    • TELETHERAPY:
      • 60 minute Session $180 per session

    PLEASE READ ADDITIONALY SERVICES and FEES:

    • IEP Meeting: $210 per-60 minutes
    • School Observation: $210 per hour observation
    • Written Report (other than Evaluation report) $180 per hour
    • Vacation Leave more that 2 consecutive weeks (14 consecutive days) will incur a $75 "time holder" policy. For example, when a client will miss three weeks of consecutive sessions, the client has an option to pay the $75 place holder to keep their same date and time for the session they are missing. If the client decides not to pay the "time holder" that time slot will become available to another client on the waiting list. 
    • WE DO NOT OFFER THERAPY EVERY OTHER WEEK. The number one reason a client is not making progress toward goals is due to dedication and frequency of therapy. 

    Payment Policy: All fees are due at the time of service.

    If you need a monthly invoice, we require that you pay at the first session of the month for the projected number of therapy sessions the client will receive during the month.  If there is an illness, we will carry-over the payment to the next month.
    I acknowledge and accept full and complete responsibility for prompt payment for all services rendered by SpeechFamily, LLC. I am responsible for filing claims with my insurance and payment for my services.

    I understand that health insurance policies and reimbursement are between myself and my health insurance company, and that all services rendered by SpeechFamily, LLC for the benefit of the client are charged directly to me, and I am personally responsible for payment in full to SpeechFamily, LLC.

    For your convenience, we accept cash or all credit cards and HSA/FSA cards via your login portal at SimplePractice.
    I understand that if my outstanding balance due to SpeechFamily, LLC for treatment becomes Two Hundred and Eighty Dollars ($300.00) or more, SpeechFamily, LLC reserves the right to withhold therapy/reports until such balance is paid in full.
    If no payment is received a 10% late fee will be charged after 30 days.  After 60 days of no payment, SpeechFamily, LLC will contact a credit agency.

     

    AGREEMENT TO TERMS OF PAYMENT
    I accept full and complete responsibility for payment of all services rendered to my child or any child under my care by SpeechFamily, LLC,. I acknowledge that I have received a written explanation of the fee schedule, cancellation policy, and payment policy and I agree to both. I understand that health insurance policies are an arrangement between my insurance and myself, that all services rendered to myself, my child child or any child under my care are charged directly to me, and that I am personally responsible for payment. I understand that agreements regarding fee schedules, charges for cancelled appointments and late payment fees are between myself and SpeechFamily, LLC and are not related to potential insurance coverage. 

    Clients will be billed on a per-session basis for services rendered. Payment is due at thetime of service. Failure to make any payment will result in the client’s services being puton hold until payments are received and your account is paid in full.

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  • Client Consent Form

    Collection, Use, and Disclosure of Personal Information
  • Privacy of your personal information is an important part of our SpeechFamily practice, while providing you with quality therapy care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.  All clinicians who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. All electronic forms and consent forms are viewed only by the clinicians at SpeechFamily, unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member. In-office forms at SpeechFamily are utilized by the staff of the centre and adhere to the appropriate use and protection of your information.   Our Privacy Policy at SpeechFamily practice outlines what we are doing to ensure that: Only necessary information is collected about you; We only share your information with your consent; Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of American Speech and Language Associations and the state of Georgia Speech and Language Board. How We Collect, Uses and Discloses Clients’ Personal Information: The Studio Clinic/ Practice of SpeechFamily understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information.  The clinic will collect, use and disclose information about you for the following purposes:  To assess your health concerns, To provide behavioral health care,  To advise you of treatment options,  To establish and maintain contact with you,  To remind you of upcoming appointments,  To communicate with other treating health-care providers,  To allow us to efficiently follow-up for treatment, care and billing,  To invoice for our therapy services,  To process credit card payments,  To collect unpaid accounts,  To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others.

    By signing this Client Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.

  • Client, Parent or Legal Guardian Consent:

  • I have reviewed the above information that explains how SpeechFamily will use my personal information and the steps that the studio/clinic is taking to protect my information.  I agree that the SpeechFamily can collect, use and disclose personal information as set out above in the information about the studio/clinic’s privacy policies. 

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  • Release Form (optional)

    Pictures                                                                                                                I give permission to SpeechFamily,LLC to take and use photographic images for the
    following purposes:
        Training and/or educational purposes                                                                      Use in marketing materials of SpeechFamily, (e.g., website, blog, brochures)

    Audio Recordings
    I give permission to SpeechFamily,LLC to take and use audio recordings for the following purposes:
        Training and/or educational purposes
        Use in marketing materials of SpeechFamily,LLC, LLC (e.g., website, blog)

    Video Recordings
    I give permission to SpeechFamily,LLC to take and use video recordings for the following purposes:
        Training and/or educational purposes
        Use in marketing materials of Graham Speech Therapy, LLC 

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  • Consent For Evaluation and/or Treatment

  • Please note that this form must be signed prior to your first appointment. 
  • Please complete the form below to grant permission and authorize a screening, comprehensive speech and language evaluation, and/or treatment (as needed) for the client. Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist, current clinical team members, current doctors, and parents/families.

    As a client you will receive information about the diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon.  The staff is trained to handle emergencies should the need arise. 

    You acknowledge and agree to receive speech and language therapy services from the certified speech language pathologist at SpeechFamily. I acknowledge that there is some risk inherent in the use of the therapy equipment and I agree to assume such risk and indemnify and hold the clinical staff at SpeechFamily, LLC. harmless from any and all losses and claims for any injuries or other damages occurring to myself, my child or our belongings.

    I understand:  - The clinic does not guarantee treatment results. - That the certified clinicians at SpeechFamily will explain to me the exact nature of any treatment provided and will answer any questions I may have.  - I am free to withdraw my consent and to discontinue treatment at any time. 

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  • Client Intake Information

  • Note: We use SimplePractice Electronic Health Records for all Patient Charts which is HIPAA-Compliant and provides industry-leading data system security. SimplePractice allows you to instantly access your records online and communicate with your clinicians securely. Login to your SimplePractice Client Portal 

  • Why do ethnic and cultural background matter? The relationship between language and culture and ethnicity is symbiotic, with language reflecting both and both shaping our language. Cultural background is heavily dependent on a number of factors including ethnicity, gender, geographic location, religion, language, and much more.  Ethnic background have a number of linguistic resources available to speakers for use in constructing ethnic identities which include the following: a heritage language, specific sociolinguistic features, code-switching, suprasegmental features, discourse features and language use, and using a borrowed variety

  • Parent / Guardian 1

  • PLEASE ENSURE the email address you enter is Accurate as this is the number one reason people are unable to access their online charts!
  • Parent / Guardian 2
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  • Health History

  • Prenatal Health

  • Child's Birth History

    Was your child:
  • Feeding and Nutrition

    For early childhood with speech/language concerns
  • Health Development

  • Approximate age your child first:

  • Speech and Language Development

  • Sensory Processing Development

  • Play Development

    Answer for children under the age of 5
  • Family History and Background

    Please describe any significant family history for the following:
  • Environment

  • Please name the school  and the grade or the classroom name     

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