Child Home Intake
Welcome!
We hope you are as excited as we are to get started on your journey to Brain Harmony.
Getting Started
- Each family member participating in therapy must complete two steps:
1. Intake paperwork which includes the required paperwork to onboard each family member into the program. This includes providing us medical history information as well as legal permission to treat and HIPPA compliance.
2. Measure of Foundational Abilities (MFA) is a self-reporting, neurological profile that provides us the necessary information to develop an individualized plan of care for each family member. You may access the MFA at www.brainharmony.com/MFA-start-here. Please use the same email address when completing the quiz and intake paperwork for all family members.
- The clinical team will review your intake paperwork for appropriateness for remote management. If we have any concerns, we will notify you.
- Lease Agreements are required for each piece of equipment or modality identified to be a part of your family’s therapy plan. These agreements were emailed to you after the consultation.
- Upon completion of the above steps, you will receive a call from the Home Office to schedule your Kick-Off Session.
- Please identify Brain Harmony Emails as not junk! Throughout your journey with us, you will receive emails before and after sessions. These emails have articles, instructional videos, and directions. Because many of these emails are system generated, they will go into your email garbage pile until you tell your email system that Brain Harmony emails are not junk.
Important Contact Information
Brain Harmony has a team approach to care. If at any time you are wondering what is next or you have any concerns, please do not hesitate to call Ellen at 727-999-9124 ext. 101 or email ellen@brainharmony.com.
Faster Stronger Smarter
We know we can improve brain organization and function in people of all ages because the brain grows, changes and creates new pathways in response to stimulation and input from the environment. We create change with frequency, duration and intensity of therapeutic input. The more therapy you complete, the faster, stronger and smarter you or your family member will become.
From Our Family to Yours,
Carol Garner-Houston, OTR/L
Co-Founder and Chief Clinical Officer, Brain Harmony
Nationally Licensed Occupational Therapist
Lara Garner Shane
Co-Founder & Chief Executive Officer
Brain Harmony

Permission to Administer Therapy
Please complete this form. By completing this form, you are giving your consent for treatment.
Name of Patient*
Parent/Guardian*
This approval includes my consent for treatment and my consent for Brain Harmony staff to share and receive information for the purpose of helping my child succeed.
I authorize this sharing of information with the following guidelines or exceptions: The patient authorizes Brain Harmony to advise, as he/she deems appropriate, through the use of iLs, and the patient gives the authorization for these protocols to be used. The patient has the right to informed participation in decisions involving his/her health care. This shall be based on clear, concise explanation of his/her condition and of all proposed treatment procedures. All possible risks and/or side effects as well as the probability of success with such procedures shall be disclosed to the patient. Bipolar and seizure disorders may be contraindicated when using iLs. Implantable devices, such as pacemakers and defibulators, and pregnancy are contraindicated for alpha stim. I understand that it is my responsibility to disclose any possibility of bipolar, seizure disorders, implantable devices and pregnancy to Brain Harmony for the safety of my child.
The patient will not hold the Brain Harmony responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. The patient shall not be subjected to any procedure without his/her voluntary, competent, and understanding consent or the consent of his legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed. After reading the above (or having it read to me), I hereby consent for my child to consultative services from Brain Harmony via iLs to begin on this date and terminating when determined by myself or my physician.
Signature of Parent/Guardian*
Clear
Date*
Month Day Year
Date

Identifying and Family information:
Patient's name:*
Date of Birth:*
Gender:*
Male Female
Age:*
Address:*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Home Phone:*
Area Code Phone Number
Cell:*
Area Code Phone Number
Email*
example@example.com
Primary Care Physician's name:
Contact Number
Area Code Phone Number

Parent information (if the patient is under 18 years of age, please fill out section below.)
Mother's Name:
Mother's Address (if different from above)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Mother's Daytime Phone:
Area Code Phone Number
Mother's Cell Phone:
Area Code Phone Number
Mother's Email
example@example.com
Father's Name:
Father's Address (if different from above)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Father's Daytime Phone:
Area Code Phone Number
Father's Cell Phone:
Area Code Phone Number
Father's Email
example@example.com

Authorization for Information Exchange
Patient Name*
First Name Last Name
Date Signed
Month Day Year
Date
I hereby authorize Therapeutic Connections, LLC. DBA Brain Harmony to give and/or receive in verbal, written, or video form information pertaining to the above-named patient.
I authorize exchange of information between Therapeutic Connections, LLC. DBA Brain Harmony and the party or parties listed below:
Name
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Area Code Phone Number
Name
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Area Code Phone Number

A photocopy of this document shall be considered to be as valid as the original. This authorization for release of information shall remain in effect until revoked and may be revoked by myself at any time by giving written notice to Therapeutic Connections, LLC. DBA Brain Harmony.
I understand that Brain Harmony may take pictures or videos of the patient to document developmental status and or clinical progress. These images and likeness of the patient will not be used without my written permission to do so.
I understand that the information obtained will be treated in a confidential manner and will not be given to a third party without my permission unless required by law.
Signature*
Clear
Date*
Month Day Year
Date

NOTICE OF PRIVACY & HIPAA PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL & PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, WHO HAS ACCESS TO YOUR INFORMATION AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
WHO WILL FOLLOW THIS NOTICE
This notice describes our institution’s practices and that of:
- Any health care professional authorized to enter information into your medical record
- All departments and units of Therapeutic Connections, LLC. DBA Brain Harmony
- Any member of a volunteer group we allow to help you while you are a patient at Therapeutic Connections, LLC. DBA Brain Harmony
- All employees, staff, affiliated/contract staff, student, business associates and other Therapeutic Connections, LLC. DBA Brain Harmony personnel.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
For treatment:
To provide, coordinate or manage your health care and related services by both us and other health care providers (doctors, nurses, hospitals, healthcare providers, and other healthcare facilities who become involved in your care)
We may refer you to another health care provider and as part of the referral, share medical information about you to that provider.
For payment:
So we can be paid for services provided to you, which can include billing you, your insurance company or a third party payer.
How we will contact you:
Unless you tell us otherwise in writing, we may contact you by either telephone, text, email or by mail at either your home or your workplace. At either location we may leave messages for you on voicemail.
Treatment Alternatives, Health Related Benefits and Services:
Your protected health information may be used to provide you with information about other healthrelated benefits or services that may be of interest to you and/or information regarding treatment alternatives.

Agreement
Your signature below confirms that you agree to the information on each page of this entire packet. Signing below also confirms that all of the information that you have provided is true to the best of your knowledge. In addition, your signature authorizes the patient’s insurance benefits be paid directly to Therapeutic Connections, LLC. DBA Brain Harmony.
I understand that I am financially responsible for any balance. I also authorize Therapeutic Connections, LLC. DBA Brain Harmony to release any information required to process my claims. Please accept my digital name below as signature authority.
Signature*
Clear
Date*
Month Day Year
Date

Developmental History for Children and Young Adults
Please take your time when completing the following developmental history. Assessment of developmental history starts from pre-conception. This allows for identification of patterns and severity of symptoms when assessing your child. This information is intended to provide the most comprehensive care possible. This information will not be released without your written consent.
Today's Date:
Month Day Year
Date
Child's Name*
Date of birth
Month Day Year
Date
Childs Age:
Reason for Seeking Care:
Age concerns developed
Has there been a regression of skills?
Yes No

Adoption - If your child is adopted, please complete.
Describe the circumstances surrounding the adoption.
Age when adopted:
Prior Foster Homes?
Response to new home:
Is child aware of adoption:

Medical History (cont.)
Has your child experienced any problems with his/her hearing? (operations, infections,tubes)
Yes No
If YES, please explain:
How many ear infections has your child had?
Has your child had ear tubes placed?
Yes No
When was the last time his/her hearing was tested?
Has your child experienced any problems with his/her eyesight or vision?
Yes No
If YES, please explain:
Does your child wear glasses or contacts?
Yes No
When was the last time his/her eyesight was tested?

Medical History (cont.)
What type of school is your child attending:
Brick and Mortar Online Hybrid Homeschool None
What therapies is your child presently participating in?
What therapies has the child tried in the past?

Medical History (cont.)
Do you have concerns regarding your child's speech development?
Yes No
If yes, please explain:
Does your child have a speech delay?
Yes No
If yes, please explain:

Goals
What are your top 4 goals for your child’s program? Please be as specific as possible.*
Is there any information you believe might be helpful to us in determining the best plan of care to achieve these goals?
Please provide any other life experiences that contribute to the child's present state of functioning:
Should be Empty:

Child Home Intake