Occupational Therapy Intake Form

Pediatric Information Form

Patient Name:    Date of Birth:    Age:    M   F

Ethnicity:    Preferred Language:

Current Diagnosis (if any):

Home Address:

Primary Phone:

School Attended:    Teacher:    Grade:

School Phone:

Child's Primary Physician:

Address/Phone:

Child's Referring Physician:

Address/Phone:

Guardian Information Section

First Guardian Name:

Relationship to Patient:    Marital Status:

Occupation:

Primary Phone:   Cell Home Work

Secondary Phone:   Cell Home Work

E-mail Address:

Second Guardian Name:

Relationship to Patient:    Marital Status:

Occupation:

Primary Phone:   Cell Home Work

Secondary Phone:   Cell Home Work

E-mail Address:

Emergency Contact:

Relationship:    Phone:

Insurance Information Section

Insurance Type:    Patient Social Security Number:

Member ID Number:    Group Number:

Policy Holder's Name:    Policy Holder's DOB:

Patient Name:    DOB:

Pediatric Occupational Therapy Intake Form

What are your primary areas of concern?

What are your goals for Occupational Therapy?

Medical History

Please Check All That Apply:

Has your child ever had significant illness? No Yes, please list:

Has your child ever been hospitalized? No Yes, please list:

Does your child have medical precautions? No Yes, please list:

Has your child ever had any surgeries? No Yes, please list:

Does your child have any allergies? No Yes, please list:

Is your child on any medications? No Yes, please list:

Is your child receiving any other services such as Speech, Physical Therapy, Special Education, Early Intervention, etc.? No Yes, where:

Check off all special equipment does your child may use:

Prenatal & Birth History

Please list any significant prenatal or birth history (weeks gestation, birth weight, APGARS):

Developmental History

Fill in the blanks to describe your child to the best of your ability

Sat at months/years    Crawled at months/years

Stood at months/years    Walked at months/years

Ran at months/years    Talked at months/years

Dressed at months/years    Fed self at months/years

Toilet trained at months/years

Please list any motor development concerns you have (i.e. gross motor, fine motor, oral motor, motor planning, fear of movement, fear of heights, etc.)

Academic History

Check off all that apply to your child:

Please list any academic concerns you have

Please list any specific teacher concerns

Evaluation & Therapy Services

Please list any previous occupational therapy evaluations completed and recommendations

Please list any previous psychological/neuropsychological/psych-educational evaluations completed and recommendations

Behavior/Social History

Check off all that apply to your child

HIPAA Release Form

Patient Name:    DOB:

Release of Information

I authorize the release of information including diagnosis, records, examination rendered to me and claims information.

Name of Referring Doctor:

Specialty:

Phone #:

Fax #:

Name of Primary Doctor:

Specialty:

Phone #:

Fax #:

Name:

Specialty / Relationship:

Phone #:

Fax #:

Name:

Specialty / Relationship:

Phone #:

Fax #:

Name:

Specialty / Relationship:

Phone #:

Fax #:

This release of information will remain in effect until terminated by patient or guardian in writing.

Patient Name:    DOB:

Consent for Treatment of Minors:

This is to certify that the information on the intake forms are accurate to the best of my knowledge. I give permission to Elite DNA Therapy Services to provide treatment for my child. I verify that all legal guardians are aware of and give consent for this treatment as well.

Policies of the Elite DNA Therapy Services

Fees for Clinical Services

At Elite DNA we accept many of the major insurance plans, single case agreements, and private pay. Please inquire about our fees, as the rates may be different depending on which provider you are seeing. Please know that you may be billed for telephone calls, written reports or other services that specifically require the provider’s time outside of the scheduled appointment.

Missed/Cancelled Appointments

A patient who fails to appear at or cancels less than 24 hours of an appointment will be charged a $100 fee and/or may no longer be seen at this clinic. Please remember to reschedule ahead of time and we will try our best to accommodate you. Since “things happen,” patients will be permitted to miss one appointment without being penalized per 6 month. However, please know that repeated “no-shows” may jeopardize your ability to receive treatment.

Lateness

Due to stringent billing requirements, we will be unable to see patients who are more than 15 minutes late for their appointment. Please call to let us know if you are running late and we will be happy to reschedule your appointment, as needed. However, you will incur the same $100 fee or stop of services if you are not able to keep your appointment.

General Medical Consent (for psychiatry)

By signing this form, the patient or the patient’s legal representative hereby consents to general and medical care, including but not limited to medical services, X-ray and laboratory examinations rendered to the patient by or under the general or special instructions of the physician practicing within the Elite DNA Therapy Services.

Emergency Services (for psychiatry only)

The on-call services are for patients of Dr. Metheny and are reserved for emergencies only. Please call: 239-223-2751 and press 9.

Confidentiality and Release of Information

All information disclosed within sessions is confidential and may not be revealed to anyone outside of the Elite DNA Therapy Services without your written permission, except for disclosures as required by law. The law does require clinicians to report to the authorities any reasonable suspicions of child or elder abuse, or danger of harm to self and/or to others unless protective measures are taken.

To the extent necessary to determine insurance benefits or liability for payment and to obtain reimbursement, Elite DNA Therapy Services may disclose portions of the patient’s medical record and account file to any person or corporation that may be liable for all or any portion of the patient’s charges, including but not limited to insurance companies, health care service plans or workers’ compensation carriers.

Financial Agreement

It is a patient’s responsibility to know his/her insurance coverage for services, as some services and general medical coverage may be provided by two separate plans. Our office staff is happy to help answer questions and help with this process.

Patients in poor credit standing with Elite DNA Therapy Services will make their co-payments or payment in full at the time of their visit. We reserve the right to assign unpaid bills to a collection agency.

If you have any questions not covered by this statement, please feel free to ask for clarification.

The undersigned certifies that he or she has read, understands, and accepts the terms and conditions of this form. The undersigned is either the patient or is duly authorized to sign this form and receive a copy.