Date
MM
DD
YYYY
Child's Name
*
First Name
Last Name
Child's Diagnosis
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
(###)
###
####
Email
*
Caregiver Name
Caregiver's relationship to child
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Additional Caregiver Name
Additional Caregiver's relationship to child
Additional Caregiver's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Additional Caregiver's Phone Number
(###)
###
####
Additional Caregiver's Email
Who referred you to our office?
Your Child's Pediatrician
If the primary person bringing child to therapy is not listed above, please list name and contact phone number o person:
Persons authorized to drop off/pick-up:
Who does the child reside with?
Who has custody of the child?
Are there any current family legal concerns we should know about? If so, please write below.
Are there any spiritual or cultural considerations we should know about? If so, please write below.
Is this child at risk for harm to themselves or others?
*
What is the Child’s primary language?
Are you in need of an interpreter?
How does your child usually communicate? (check all that apply)
Child's siblings
Please include age and gender for each child listed
What are your primary concerns about this child?
If other specialists have seen the child, please indicate the type of specialist (i.e. Physician, audiologist, psychologist, special education teacher, ABA, speech therapist, etc.)
Are you currently receiving any other Family therapy, support group, social group, or specialized recreational activities? If so, list below.
Length of Pregnancy:
Length of Labor:
Child’s Birth Weight:
Were there any unusual conditions that may have affected the pregnancy or birth?
Rolled over
Sat alone
Pulled to stand
Stood alone
Walked alone
Fed Self
Babbled
Drank from a cup
Used a spoon
Toilet Trained
Dressed Self
Does the child have difficulty walking, running, or participating in other activities which require small or large muscle coordination?
Additional Comments
Describe the child’s response to sensory stimuli such as sound, touch, taste and movement (e.g. under awareness, overly sensitive, becomes distressed).
How does the child interact with others? (children, caregivers, and other adults)?
Is there any other information that might be helpful in the evaluation or remediation of the child’s condition?
Are there or have there ever been any feeding problems? (e.g. problems with sucking, swallowing, drooling, chewing)
If yes, please describe
Was your child bottle fed or breast fed, and for how long?
Does your child have any colic or reflux issues?
If yes, please describe
Describe your child’s current eating habits and typical intake:
Additional Comments of Feeding:
Describe your child’s current eating habits and typical intake:
As legal guardian of
First Name
Last Name
Sign
Date
MM
DD
YYYY
Emergency Contact information
First Name
Last Name
Phone
(###)
###
####
Relationship to child
Medications (Include prescription drugs, over the counter meds, vitamins, and homeopathic medications:
Allergies/Reactions:
Diagnoses (any known medical diagnosis or medical condition, with dates of diagnosis if known):
Has the child had any surgeries? If so, please list the surgery and the date
Please identify any dietary restriction with your child that you would like us to be aware of:
Primary Insurance company name:
Insured's name
First Name
Last Name
Insured's date of birth
MM
DD
YYYY
Subscriber's ID #
Group Name
Group Number
Secondary Insurance Company Name
Insured's name
First Name
Last Name
Insured's date of birth
MM
DD
YYYY
Subscriber's ID
Group Name
Group Number
Additional Insurance
I give my permission for Photos/videos of my child to be used for the purposes of treatment, education, and documentation
I give my permission for photos/video of my child to be used for advertising, brochure, and/or webspace
EMAIL: I give permission to Desert OT for Kids, Inc. to correspond with my child’s legal guardians and care team via email regarding treatment, documentation, and home programming. I understand that once an email is sent externally, correspondence may potentially be intercepted by an outside party
TEXT: I authorize Desert OT for Kids, Inc. to send text messages to my cell phone related to my child’s therapy. I understand that communication via text message is not secure and may potentially be intercepted by a third party. I understand that standard data and text messaging rates will apply to any messages received from AFK. I agree not to hold AFK liable for any electronic messaging charges or fees
I hereby give Desert OT for Kids, Inc. permission to evaluate and treat my child, and I understand there will be written, oral, and electronic communication between care providers/physicians, insurance companies, and Desert OT for Kids, Inc. staff.
First Name
Last Name
Date
MM
DD
YYYY
I will bring my child to therapy, participate in sessions, and carry through with therapist recommendations at home.
First Name
Last Name
Date
MM
DD
YYYY
I understand that state representatives for the purpose of insurance certification or licensing and quality assurance may review my child’s records. I understand that all practices of confidentiality will be followed in use of the information gathered.
First Name
Last Name
Date
MM
DD
YYYY
I give consent for my child to receive occupational therapy via synchronous teletherapy when indicated.
Email for Teletherapy:
I consent to have a telemedicine facilitator (e.g., parent, guardian, or caregiver) present for teletherapy sessions. The telemedicine facilitator agrees to become competent with the telemedicine technology with training from my child's therapist and will assist my child in understanding and using this technology at the direction of my therapist. The facilitator will be on the premises and physically present if appropriate.
I consent to have a telemedicine facilitator (e.g., parent, guardian, or caregiver) present for teletherapy sessions. The telemedicine facilitator agrees to become competent with the telemedicine technology with training from my child's therapist and will assist my child in understanding and using this technology at the direction of my therapist. The facilitator will be on the premises and physically present if appropriate.
I provide consent for my therapist to send all records regarding telemedicine sessions to my child's primary care physician.
Parent/Legal Guardian signature
First Name
Last Name
Please review and initial all statements below:
Two consecutive no-shows may require your child to be placed on a hold status until the issue of missed appointments are resolved. If a resolution is not made within 5 business days, your child will lose his/her therapy time and be placed on our information list.
We require an 80% attendance rate and may need to remove the patient from the therapist's schedule if efforts are not made to maintain this rate. Note: We calculate attendance quarterly and, as a courtesy, will notify you if your percentage drops below the required 80%.
Child may not come into the clinic within 24 hours of having the following symptoms: Fever, vomiting, diarrhea, sore throat or runny nose.
I have checked with my insurance company prior to this therapy visit and assert that I have obtained the necessary information regarding limits of coverage, co-pays, and co-insurance.
I give DOT for Kids, Inc. permission to submit bills directly to the insurance carrier. I hereby understand the above financial policy and agree to abide by it.
Please sign that you have read and agree to the financial policy
First Name
Last Name
