Intake Form

Speech Therapy Intake Form
Child's Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child's Gender *

Male Female
Mobile Phone Number *

Area Code Phone Number
Other Phone number

Area Code Phone Number
Parent's Email *
Martial Status *
Spouse's Name
Spouse's Phone number
Children's Name and Ages
Primary Care Physician's Name *
Primary Care Physician's Number *

Area Code Phone Number
Primary Care Physician Practice Name and Location *
Please describe your concerns about your child's development *

Therapy Information
Is your child in Babies Can't Wait *

Yes No
Name of Service Coordinator
Phone Number of Service Coordinator

Area Code Phone Number
Please List therapies your child is receiving:
Type of Therapy
Type of Therapy
Type of Therapy
Frequency of therapy
Frequency of therapy
Frequency of therapy
Upload current IFSP

Educational Information
Is your child currently enrolled in school *

Yes No
If Yes, where and which days attended?
Does your child receive services through the school *

Yes No
Does your child have a current Individulized Educaiton Plan (IEP) *

Yes No
If you checked YES and your child is covered by Georgia Medicaid please provide a copy of your child's IEP as required by Georgia Medicaid
Upload current IEP
Please include any information not included on this form
Upload current speech evaluation

Insurance Information: Please understand you are financially responsible for what your insurance doesn't cover.
How do I plan to pay for therapy *

I will use my insurance Self-Pay
Primary Insurance company
Primary Insured Name
Primary Insured DOB
Insurance contact number
Member ID
Specialist co-payment
Individual deductible amount
Deductible met

Yes No
Referral needed for speech therapy

Yes No
Upload Front Insurance Card
Upload Back Insurance Card
Please sign the box below indicating that you will pay for therapy if your insurance does not cover services
Responsible Party *

First Name Last Name
Today's Date *

Month Day Year

Consent to Bill and Treat
CONSENT FOR TREATMENT

I am aware that my child has has a diagnosis requiring speech therapy, voluntarily consent to such care for the aforementioned child by CommuniCare Therapy Services, Inc. as may be beneficial in the professional judgment of this child’s therapist.

I am aware that the practice of speech therapy is not an exact science and I acknowledge that no guarantee has been made to me as to the effect of speech therapy treatment for my child.
Responsible Party *

First Name Last Name
Today's Date *

Month Day Year
RELEASE OF TREATMENT

I hereby authorize CommuniCare Therapy Services, Inc. to release to my Insur ance Companies only such

therapeutic and financial information as may be necessary to determine benefits entitled and to process payment claims for therapy services that will be provided. I hereby authorize CommuniCare Therapy Service Inc. to release to attending physicians and therapist therapeutic and financial information as may be necessary to coordinate my Child’s therapy plan of care.
Responsible Party *

First Name Last Name
Today's Date *

Month Day Year
CONSENT FOR PAYMENT

I authorize CommuniCare Therapy Services, Inc. to bill my insurance company for direct reimbursement of therapy services rendered to my child. Benefit payment will be assigned directly to CommuniCare Therapy Services, Inc. c/o Lisa Lester. I understand the Medicaid r ate will be accepted and billed if Georgia Medicaid covers my child. If I am not covered by Georgia Medicaid, I will be charged a maximum of $250 for Speech Therapy Evaluation and $150 for any Speech Therapy Treatment not covered by my insurance company.I understand that I am responsible for payment for any service rendered to my child not covered up to the rates mentioned above.
Responsible Party *

First Name Last Name
Today's Date *

Month Day Year
Signature *
Enter the message as it's shown *
I attest that my child has not received speech therapy within the past 6 months from another clinic. *
I wish to receive therapy services at Communicare Therapy Services and cancel services at the previous clinic I was receiving services from.

Clear
Should be Empty:

Speech Therapy Intake Form

Medical History

Please list any physicians or specialist that provide care for your child

Social/Emotional History

Feeding history: At what age was your child introduced to:

Therapy Information

Please List therapies your child is receiving:

Educational Information

If you checked YES and your child is covered by Georgia Medicaid please provide a copy of your child's IEP as required by Georgia Medicaid

Insurance Information: Please understand you are financially responsible for what your insurance doesn't cover.

Please sign the box below indicating that you will pay for therapy if your insurance does not cover services

Consent to Bill and Treat