Intake Introduction- Allen · 2016. 6. 28. · Patient!Intake!Form!!!!!*All!Fields!Required!!!! 800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!Allen,!TX!75013

!!!!!!!“Therapy)With)A)Purpose”)

!800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!

Dear!New!Family,!!

Welcome!to!Cutting!Edge!Pediatric!Therapy!(CEPT)!! ! !We!are!excited!to!have!the!opportunity!to!assist!your! child! in! their! occupational! therapy! care.! Our! therapists! strive! to! provide! the! highest! quality!treatment! using! the! most! current! and! innovative! therapy! treatments! currently! available,! in! a!professional! and! caring! manner.! ! We! are! committed! to! helping! you! identify! your! child’s! needs! and!achieve!their!goals,!while!striving!to!meet!our!mission,!“Therapy!with!a!Purpose”.!!Our!sincerest!belief!is!that!every!intervention!will!have!a!purposeful!outcome!for!all!of!our!clients.!!!

CEPT! provides! therapy! for! both! children! and! adults.!We! specialize! in! the! individualized! treatment! of!each! patient! and! their! family! structure.! Our! treatment! modalities! include! Craniosacral/Myofacial!Release!therapy,!Fine!and!Gross!Motor!Skills,!Functional!Activity!Training!(ADl],!OT!Intensive!Programs,!Oral! Motor/Feeding! therapy,! The! Listening! Program,! TLP/Bone! Conduction,! Therapeutic! Listening!Program,!and!Interactive!Metronome.!Our!therapists!specialize!in!multiFtypes!of!treatment!techniques!for!the!Vestibular!System.!!CEPT!is!also!a!teaching!clinic!so!on!occasion!students!from!various!colleges!may!accompany!your!child's!therapist,!observe!treatment!and!have!sight!of!their!notes.!Please!let!me,!your!child’s!therapist,!or!our!office!staff!know!if!this!is!a!concern!for!you.!!

Enclosed! is! the! New! Patient! Intake! Packet.! Please! read! the! information! carefully,! fill! out! all! the!documents,!and!return!to!us!at!least!2!days!prior!to!your!child’s!evaluation!appointment.!!Please!note!that!payment!is!due!at!the!time!of!the!evaluation.!!We!accept!cash,!checks,!Visa,!MasterCard,!Discover,!and!American!Express.!!Checks!are!to!be!made!payable!to!CEPT.!!Should!you!wish!to!pay!by!credit!card,!please!have!your!driver's! license!and!credit!card!with!you!at! the! time!of!your!appointment.! !A!photo!copy!of!both!will!be!kept!on!file!with!your!Credit!Card!Policy!Agreement!form.!!

CEPT! is! an! inFnetwork!provider!with!Blue!Cross!Blue!Shield! (BCBS)! and! files!outFof!network! insurance!claims! with! traditional! Medicaid,! United! Healthcare! (UHC),! Aetna,! Cigna,! and! Humana! Insurance!companies.!At!this!time,! it!will!be!the!patient’s!responsibility!to!determine!the!proper!coverage!for!all!other! insurance! carriers! and! to! contact! their! insurance! company! regarding! their! outFofFnetwork!deductible!and!benefits!prior!to!the!appointment.!You!will!need!to!pay!inFfull!for!each!appointment!and!receive! reimbursement! from! your! insurance! company! in! accordance!with! the! terms! of! your! contract!with!them.!Once!we!receive!your!insurance!information,!we!can!schedule!your!child’s!evaluation.!Your!child’s!initial!evaluation!will!last!approximately!two!hours.!Your!therapist!will!then!schedule!a!followFup!appointment!to!discuss!the!evaluation!and!treatment!options!with!you.!!

I! can!never!effectively! communicate!our!passion!and!enthusiasm! for! the! innovative!ways! that!we!are!reaching!patients!through!our!treatments!here!at!CEPT.!!It!is!our!sincere!desire!to!partner!with!you!and!your!child!as!we!start!this!new!and!exciting!journey!together.!

!

With!kind!regards,!!!!Kate!Lundgren,!OTR,!MBA,!SIPT!Owner!and!Director,!CUTTING!EDGE!PEDIATRIC!THERAPY!!

!!!!Patient!Intake!Form!!!!!!*All!Fields!Required!

!!!

800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675L3153!!!!!Fax:!(469)!675L3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769L1015!!!!!Fax:!(281)!717L8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!!

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!!Patient!Name!___________________________________________!Date!of!Birth!___________________!Gender_______________!Age__________!!Preferred!Name!____________________________!Marital!Status!of!Parents_____________________!Patient’s!SS#!_________________________!!Please!select!the!type!of!therapy!to!be!received:!!

!! ! Occupational!Therapy! ! ! Physical!Therapy! ! ! ! Speech!Therapy!!

! ! ! ! ! ! !!!!(Katy!Only)! ! ! ! !!!!(Allen!Only)!!

Pediatrician/Physician!Name!____________________________________!Phone!#!________________________!Fax#!_______________________!!Pediatrician/Physician!Address___________________________________________________!City__________________!State/Zip_____________!!Previous!OT/PT/Speech!Treatment!______________!When/!Where________________________________________________________________!!Child!lives!with______________________________________________!Siblings/Ages!_________________________________________________!

!Is!child!attending!school?!__________________________________!Where?!________________________________________________________!!How!did!you!hear!about!Cutting!Edge!Pediatric!Therapy?!!_______________________________________________________________________!!Does!your!child!have!any!medical!diagnoses!or!medical!concerns!that!CEPT!should!be!aware!of?!________________________________________!!______________________________________________________________________________________________________________________!

!Allergies/Restrictions!____________________________________________________________________________________________________!!______________________________________________________________________________________________________________________!

!Child’s!Daily!Routine!_____________________________________________________________________________________________________!!______________________________________________________________________________________________________________________!!Child’s!Interests!_________________________________________________________________________________________________________!!______________________________________________________________________________________________________________________!!Does!your!child!have!any!behavioral!concerns?!(Biting,!Pinching,!Kicking,!etc.)!If!so,!please!specify:!______________________________________!!______________________________________________________________________________________________________________________!!Parent!Goals/Notes!______________________________________________________________________________________________________!!______________________________________________________________________________________________________________________!!______________________________________________________________________________________________________________________!

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Parent/Guardian!Information!!!

Responsible!Party’s!Name!__________________________________________!DOB!___________________!Relationship!____________________!

Drivers!License!#!_______________________!State!Issued!________________!Email!Address!__________________________________________!

Home!Address!________________________________________________________!City!_______________________!State/Zip!_______________!

Home!#!_________________________________!Cell!#_______________________________!Work!#!____________________________________!

SS#_____________________________!Employer___________________________________________!Title_______________________________!

Guardian!_____________________________________________!DOB_____________________!Relationship!_____________________________!

Drivers!License!#!_______________________!State!Issued!________________!Email!Address!__________________________________________!

Home!#!________________________________!Cell!#__________________________________!Work!#!__________________________________!

Emergency!Contact___________________________________!Phone!#!______________________!Relationship___________________________!

!Insurance!Information!Required!!!

Insurance!Co.!___________________________!Claims!Phone!#!_______________________!Group!#!_______________!Policy!#______________!!Claims!Address!_____________________________________________________!City!_______________________!State/Zip!_________________!

Insurer!______________________________!DOB!_________________!SS#!__________________!Relationship!to!Patient____________________!

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Sensory(Motor(History((

Confidential+Medical+Records++++

++800+N.+Watters+Rd.,+Ste.+150+ + +++++ + + + + + ++21703+Kingsland+Blvd.,+Ste.+100++++++++++++++++Allen,+TX+75013+ + + +++++ + + + + + + Katy,+TX+77450+Tel:+(469)+675K3153+++++Fax:+(469)+675K3154+++++ + + + + + ++++++++++++++++++++Tel:+(281)+769K1015+++++Fax:+(281)+717K8947+++++++++Email:[email protected]+ + + + + + + + +++++Email:[email protected]++

+Patient+Name:+____________________________+Name+of+Person+Completing+Form:++________________________++Some+of+these+questions+may+not+reflect+the+age+of+the+person+you+are+describing.++Please+skip+these+if+they+do+not+pertain+to+your+child.++You+may+add+narrative+on+the+back+for+a+more+specific+description+of+your+child.++Mother’s(Health(History((Is+child+adopted+______)+ ++++++++ + ++(If+so,+at+what+age?+_________)+ + (Specify+country?+________________)++1.++Infections/illness+during+pregnancy?+ + + + YES+ + NO++++++Describe+_____________________________________________________________________________________________+2.++Have+any+shocks+or+abnormal+stresses+during+pregnancy?+ + YES+ + NO++++++Describe+_____________________________________________________________________________________________+3.++Did+Mother’s+water+break+24+hours+before+delivery?+ + YES+ + NO+ ++++++Describe+_____________________________________________________________________________________________+4.++Did+Mother+develop+Toxemia+or+high+blood+pressure?+ + YES+ + NO++++++Describe+_____________________________________________________________________________________________+5.++Did+Mother+have+any+complications+during+labor+and/or+delivery?+ YES+ + NO++++++Describe+_____________________________________________________________________________________________+6.++Mother’s+age+at+delivery+_____________+Length+of+pregnancy+_______________++7.++Child’s+birth+weight+___________________+Weight+upon+discharge+from+hospital+__________________+8.++Apgar+Scores:++1+minute+______________________________+5+minutes+____________________________++Child’s(Birth+ + + + + YES+ NO+ COMMENT+1.+++Full+Term+ + + + + _____+ _____+++ _____________________________________________+2.+++Premature+ + + + + _____+ _____+++ _____________________________________________+3.+++Cesarean+section++ + + + _____+ _____+++ _____________________________________________+4.+++Require+Pitocin+ + + + _____+ _____+++ _____________________________________________+5.+++Breech+(feet+first)+ + + + _____+ _____+++ _____________________________________________+6.+++Face+presentation+ + + + _____+ _____+++ _____________________________________________+7.+++Transverse+(sideways)+ + + + _____+ _____+++ _____________________________________________+8.+++Have+cord+wrapped+around+neck+ + _____+ _____+++ _____________________________________________+9.+++Require+forceps+ + + + _____+ _____+++ _____________________________________________+10.+Have+any+birth+injuries++ + + _____+ _____+++ _____________________________________________+11.+Require+a+fetal+monitor+ + + _____+ _____+++ _____________________________________________+12.+Have+insufficient+oxygen+ + + _____+ _____+++ _____________________________________________+13.++Cried+right+away+ + + + _____+ _____+++ _____________________________________________+14.++Require+intensive+care/hospitalization+ + _____+ _____+++ If+so,+how+long_________________________________+15.++Respiratory+problems+ + + + _____+ _____+++ _____________________________________________+

+Sensory(Motor(History((

Confidential+Medical+Records+++

++++800+N.+Watters+Rd.,+Ste.+150+ + +++++ + + + + + ++21703+Kingsland+Blvd.,+Ste.+100++++++++++++++++Allen,+TX+75013+ + + +++++ + + + + + + Katy,+TX+77450+Tel:+(469)+675K3153+++++Fax:+(469)+675K3154+++++ + + + + + ++++++++++++++++++++Tel:+(281)+769K1015+++++Fax:+(281)+717K8947+++++++++Email:[email protected]+ + + + + + + + +++++Email:[email protected]++

+ + + + + + + + + + + + + (Page+2)+

+ + + + + + YES+ NO+ COMMENT+ +16.++Need+a+respirator+ + + + _____+ _____+++ If+so,+how+long_________________________________+17.++Small+for+gestational+age+ + + _____+ _____+++ _____________________________________________+18.++Heart+defect+ + + + + _____+ _____+++ _____________________________________________+19.++Require+an+exchange+transfusion+ + _____+ _____+++ _____________________________________________+20.++Jaundiced+ + + + + _____+ _____+++ If+so,+how+long_________________________________+21.++Seizures+ + + + + _____+ _____+++ _____________________________________________+22.++Infections+at+birth+ + + + _____+ _____+++ _____________________________________________+23.++Surgery+at+birth+ + + + _____+ _____+++ _____________________________________________+24.++Feeding+problems+at+birth++++++ + + _____+ _____+++ _____________________________________________++Taste(and(Smell+ + + + + YES+ NO+ USED+ COMMENT+1.++++Act+as+though+all+food+taste+the+same+ + _____+ _____+++ _____+ ______________________________________+2.++++Avoid+and+crave+certain+foods+ + + _____+ _____+++ _____+ ______________________________________+3.++++Chew+on+nonKfood+items+ + + _____+ _____+++ _____+ ______________________________________+4.++++Feeding+problems+ + + + _____+ _____+++ _____+ ______________________________________+5.++++Trouble+changing+to+textured+food+ + _____+ _____+++ _____+ ______________________________________+6.++++Sensitive+to+unusual+smells+ + + _____+ _____+++ _____+ ______________________________________+7.++++Taste/smell+toys,+clothes,+etc.+(more+than+usual)+_____+ _____+++ _____+ ______________________________________++Muscle(Tone+ + + + + YES+ NO+ USED+ COMMENT+1.++++Feels+heavier+than+he+looks+ + + _____+ _____+++ _____+ ______________________________________+2.++++Has+good+endurance+ + + + _____+ _____+++ _____+ ______________________________________+3.++++Have+diagnosed+muscle+problems+ + _____+ _____+++ _____+ ______________________________________+4.++++Has+flat+feet+ + + + + _____+ _____+++ _____+ ______________________________________+5.++++Slump+when+sitting+ + + + _____+ _____+++ _____+ ______________________________________+6.++++Get+tired+easily+ + + + _____+ _____+++ _____+ ______________________________________+7.++++Seems+generally+weak++ + + _____+ _____+++ _____+ ______________________________________+8.++++Keep+mouth+open+ + + + _____+ _____+++ _____+ ______________________________________+9.++++Prefer+to+lie+on+back+as+infant+rather+than+tummy+_____+ _____+++ _____+ ______________________________________++Coordination(and(Development++ + + YES+ NO+ USED+ COMMENT+1.++++Creeping/crawling+phase+unusually+prolonged+ _____+ _____+++ _____+ ______________________________________+2.++++Are+movements+slow,+prodding,+deliberate+ _____+ _____+++ _____+ ______________________________________+3.++++Difficulty+with+sequential+tasks+ + + _____+ _____+++ _____+ ______________________________________++++++++(dressing,+buttoning,+zippering,+shoe+tying+–+circle+ones+that+are+difficult+for+child+4.++++Have+difficulty+learning+to+hold+a+pencil/crayon++++_____+ _____+++ _____+ ______________________________________+5.++++Creep+on+tummy+or+bottom+ + + _____+ _____+++ _____+ ______________________________________++

+Sensory(Motor(History(



+ + + + + + + + + + + + + (Page+3)+

+ + + + + + YES+ NO+ USED+ COMMENT+6.++++Clumsy+playing+on+toys+ + + _____+ _____+++ _____+ ______________________________________+7.++++Trip+or+fall+often+ + + + _____+ _____+++ _____+ ______________________________________+8.++++Seem+clumsy+or+awkward+ + + _____+ _____+++ _____+ ______________________________________+9.++++Bump+into+things+often+ + + _____+ _____+++ _____+ ______________________________________+10.++Dominant+hand:++ + + + Left+_________+Right+________++11.++Has+poor+handwriting++ + + _____+ _____+++ _____+ ______________________________________+12.++Eats+neatly+for+age+ + + + _____+ _____+++ _____+ ______________________________________+13.++Has+rigid+movements+ + + + _____+ _____+++ _____+ ______________________________________+14.++Hand+shaky+in+fine+motor+movements+ + _____+ _____+++ _____+ ______________________________________+15.++Enjoys+sports,+gym,+etc.+ + + _____+ _____+++ _____+ ______________________________________+16.++Child’s+age+for+independent+activity:++ + +Sitting+________Standing+_______+Crawling+________+Walking________+++Auditory( + + + + YES+ NO+ USED+ COMMENT+1.++++Diagnosed+hearing+problem+ + + _____+ _____+++ _____+ ______________________________________+2.++++Frequent+ear+infections+ + + _____+ _____+++ _____+ ______________________________________+3.++++Requires+tubes+in+ears++ + + _____+ _____+++ _____+ ______________________________________+4.++++Sensitive+to+sound+ + + + _____+ _____+++ _____+ ______________________________________+5.++++Responds+negatively+to+unexpected+sounds+ _____+ _____+++ _____+ ______________________________________+6.++++Fear+of+particular+sounds+ + + _____+ _____+++ _____+ ______________________________________+7.++++Distracted+by+sounds+(i.e.,+fans,+heaters,+fridge)+ _____+ _____+++ _____+ ______________________________________+8.++++Confused+which+direction+sounds+come+from+ _____+ _____+++ _____+ ______________________________________+9.++++Likes+to+make+loud+noises+ + + _____+ _____+++ _____+ ______________________________________+10.++Has+difficulty+repeating+rhythmical+sounds+ _____+ _____+++ _____+ ______________________________________+11.++Fails+to+follow+through+when+requested+to++ _____+ _____+++ _____+ ______________________________________+++++++++do+something+ + + + _____+ _____+++ _____+ ______________________________________+12.++Unable+to+function+if+2K3+part+commands+are++++++++++given+at+once+ + + + _____+ _____+++ _____+ ______________________________________+13.++Talks+excessively+ + + + _____+ _____+++ _____+ ______________________________________+14.++Talking+interferes+with+listening++ + _____+ _____+++ _____+ ______________________________________+15.++Has+speech+or+language+delay+ + + _____+ _____+++ _____+ ______________________________________++Tactile( + + + + + YES+ NO+ USED+ COMMENT+1.++++Likes+to+be+touched+ + + + _____+ _____+++ _____+ ______________________________________+2.++++Dislikes+being+held+or+cuddled+ + + _____+ _____+++ _____+ ______________________________________+3.++++Prefers+to+touch+rather+than+be+touched++ _____+ _____+++ _____+ ______________________________________+4.++++Seems+excessively+ticklish+ + + _____+ _____+++ _____+ ______________________________________+++

(((((((((Sensory(Motor(History(Confidential+Medical+Records+

+++800+N.+Watters+Rd.,+Ste.+150+ + +++++ + + + + + ++21703+Kingsland+Blvd.,+Ste.+100++++++++++++++++Allen,+TX+75013+ + + +++++ + + + + + + Katy,+TX+77450+Tel:+(469)+675K3153+++++Fax:+(469)+675K3154+++++ + + + + + ++++++++++++++++++++Tel:+(281)+769K1015+++++Fax:+(281)+717K8947+++++++++Email:[email protected]+ + + + + + + + +++++Email:[email protected]++

+ + + + + + + + + + + + + (Page+4)+

( + + + + + YES+ NO+ USED+ COMMENT+5.++++Seems+easily+irritated+or+enraged+when+touched+ ++++++++by+siblings+or+playmates+ + + _____+ _____+++ _____+ ______________________________________+6.++++Has+strong+need+to+touch+objects/people+ _____+ _____+++ _____+ ______________________________________+7.++++Seems+to+pick+fights+ + + + _____+ _____+++ _____+ ______________________________________+8.++++Pinches,+bites+or+otherwise+hurts+himself/others+ _____+ _____+++ _____+ ______________________________________+9.++++Frequently+bumps+or+pushes+others+ + _____+ _____+++ _____+ ______________________________________+10.++Bangs+head+on+purpose+ + + _____+ _____+++ _____+ ______________________________________+11.++Dislikes+the+feeling+of+certain+clothing+ + _____+ _____+++ _____+ ______________________________________+12.++Over+or+underdresses+for+the+temperature+ _____+ _____+++ _____+ ______________________________________+13.++Overheats+easily+ + + + _____+ _____+++ _____+ ______________________________________+14.++Seems+overly+sensitive+to+food/water+temp.+ _____+ _____+++ _____+ ______________________________________+15.++Seems+overly+sensitive+to+different+food+texture+ _____+ _____+++ _____+ ______________________________________+16.++Prefer+tub+baths+over+showers+ + + _____+ _____+++ _____+ ______________________________________+17.++Likes+to+play+in+water,+sand,+mud,+clay+ + _____+ _____+++ _____+ ______________________________________+18.++Seems+to+lack+normal+awareness+of+being++++++++++Touched+ + + + + _____+ _____+++ _____+ ______________________________________+19.++Often+seems+unaware+of+cuts,+bruises+ + _____+ _____+++ _____+ ______________________________________+20.++Avoids+using+hands+ + + + _____+ _____+++ _____+ ______________________________________+21.++Examine+objects+or+clothes+with+hands+ + _____+ _____+++ _____+ ______________________________________+22.++Walks+on+toes+ + + + _____+ _____+++ _____+ ______________________________________+23.++Dislikes+haircuts+or+nail+trimming+ + _____+ _____+++ _____+ ______________________________________+24.++Chews+on+objects+or+clothes+ + + _____+ _____+++ _____+ ______________________________________++Vestibular:+ + + + + YES+ NO+ USED+ COMMENT+1.+++++Arches+back+when+held+or+moved+as+baby+ _____+ _____+++ _____+ ______________________________________+2.+++++Enjoyed+being+rocked++ + + _____+ _____+++ _____+ ______________________________________+3.+++++Likes+being+tossed+in+air+ + + _____+ _____+++ _____+ ______________________________________+4.+++++Like+fast+spinning+carnival+rides+ + _____+ _____+++ _____+ ______________________________________+5.+++++Like+to+swing++ + + + _____+ _____+++ _____+ ______________________________________+6.+++++Spin+or+whirls+more+than+other+children++ _____+ _____+++ _____+ ______________________________________+7.+++++Gets+carsick+easily+ + + + _____+ _____+++ _____+ ______________________________________+8.+++++Gets+nauseous+and/or+vomits+from+movement+ _____+ _____+++ _____+ ______________________________________+9.+++++Rocks+while+sitting+ + + + _____+ _____+++ _____+ ______________________________________+10.+++Jumps+a+lot+ + + + + _____+ _____+++ _____+ ______________________________________+11.+++Has+fear+of+space+(stairs,+heights,+crawl+tunnels)+_____+ _____+++ _____+ ______________________________________+12.+++Loses+balance+easily+ + + + _____+ _____+++ _____+ ______________________________________+13.+++Misunderstands+the+meaning+of+words+used+in+++++++++relation+to+movement+and+direction+++ + _____+ _____+++ _____+ ______________________________________++

(((((((((((Sensory(Motor(History((



+ + + + + + + + + + + + + (Page+5)+

(Visual+ + + + + + YES+ NO+ USED+ COMMENT+1.++++Diagnosed+visual+problem+ + + _____+ _____+++ _____+ ______________________________________+2.++++Seems+very+sensitive+to+light+ + + _____+ _____+++ _____+ ______________________________________+3.++++Has+trouble+following+their+eyes+ + _____+ _____+++ _____+ ______________________________________+4.++++Avoids+eye+contact+ + + + _____+ _____+++ _____+ ______________________________________+5.++++Distracted+by+visual+contact+ + + _____+ _____+++ _____+ ______________________________________+6.++++Dislikes+having+eyes+covered+ + + _____+ _____+++ _____+ ______________________________________+7.++++Able+to+close+eyes+for+short+periods+of+time+ _____+ _____+++ _____+ ______________________________________+8.++++Makes+reversals+when+copying+or+reading+ _____+ _____+++ _____+ ______________________________________+9.++++Prefers+playing+in+the+dark+ + + _____+ _____+++ _____+ ______________________________________+10.++Has+trouble+discriminating+shapes,+colors+ _____+ _____+++ _____+ ______________________________________+11.++Squints+often++ + + + _____+ _____+++ _____+ ______________________________________+12.++Able+to+look+at+something+far+away+ + _____+ _____+++ _____+ ______________________________________+13.++Able+to+look+at+something+close+ + _____+ _____+++ _____+ ______________________________________+14.++Blinks+or+turns+face+away+when+a+ball+is++++++++++thrown+at+them+ ++ + + _____+ _____+++ _____+ ______________________________________++Behavior(or(Temperament+ + + YES+ NO+ USED+ COMMENT+1.++++Calm+or+relaxed+ + + + _____+ _____+++ _____+ ______________________________________+2.++++Active,+outgoing,+enthusiastic+ + + _____+ _____+++ _____+ ______________________________________+3.++++Intense,+easily+frustrated,+anxious+ + _____+ _____+++ _____+ ______________________________________+4.++++Explosive+ + + + + _____+ _____+++ _____+ ______________________________________+5.++++Cried+excessively+in+infancy++ + + _____+ _____+++ _____+ ______________________________________+6.++++Clingy+ + + + + _____+ _____+++ _____+ ______________________________________+7.++++Rigid,+set+in+ways+ + + + _____+ _____+++ _____+ ______________________________________+8.++++Adaptable,+flexible+ + + + _____+ _____+++ _____+ ______________________________________+9.++++Regular+sleep+patterns++ + + _____+ _____+++ _____+ ______________________________________+10.++Difficult+to+get+to+sleep+ + + _____+ _____+++ _____+ ______________________________________+11.++Wakes+frequently+ + + + _____+ _____+++ _____+ ______________________________________+12.++Screams+when+wakes+during+night+ + _____+ _____+++ _____+ ______________________________________+13.++Short+attention+span+ + + + _____+ _____+++ _____+ ______________________________________+14.++Distractible+ + + + + _____+ _____+++ _____+ ______________________________________+15.++Demonstrates+selfKstimulating+behaviors+ _____+ _____+++ _____+ ______________________________________+16.++Display+extreme+mood+changes+ + _____+ _____+++ _____+ ______________________________________+17.++Unable+to+adjust+to+routine+changes+ + _____+ _____+++ _____+ ______________________________________+18.++Expresses+feelings+of+failure/frustration+ + _____+ _____+++ _____+ ______________________________________+19.++Expresses+feelings+of+low+selfKesteem+ + _____+ _____+++ _____+ ______________________________________+20.++Seems+discouraged+or+depressed+++ + _____+ _____+++ _____+ ______________________________________+

+(((((((((Sensory(Motor(History((

++++++++Confidential+Medical+Records+++


+ + + + + + + + + + + + + (Page+6)+

+School?Aged(Children(Only+ + + YES+ NO+ USED+ COMMENT+ +1.++++Recognizes+own+errors+ + + _____+ _____+++ _____+ ______________________________________+2.++++Learns+from+mistakes+ + + + _____+ _____+++ _____+ ______________________________________+3.++++Acquires+materials+needed+for+a+task+ + _____+ _____+++ _____+ ______________________________________+4.++++Able+to+setKup+a+workspace+ + + _____+ _____+++ _____+ ______________________________________+5.++++Maintain+work+space+ + + + _____+ _____+++ _____+ ______________________________________+6.++++Able+to+work+independently+ + + _____+ _____+++ _____+ ______________________________________+7.++++Generalize+known+skills+to+acquire+new+skills+ _____+ _____+++ _____+ ______________________________________+8.++++Asks+for+help+appropriately+ + + _____+ _____+++ _____+ ______________________________________+9.++++Plans+ahead++ + + + + _____+ _____+++ _____+ ______________________________________+10.++Comprehends+ageKappropriate+content+in+++++++++written+language+ + + + _____+ _____+++ _____+ ______________________________________+11.++Gets+work+done+on+time+ + + _____+ _____+++ _____+ ______________________________________+12.++Average+reading+level+ + + + _____________________+13.++Average+math+level+ + + + _____________________+14.++I.Q.+(Confidential)+ + + + _____________________+15.++Current+placement+in+school+ + + _____+ _____+++ _____+ ______________________________________++++This%case%history%is%compiled%and%adapted%from%A.J.Ayres,%Ph.D;%Patricia%Wilbarger,%MED,%OTR.;%Montgomery/Richter,%1977,%Knickerbocker%and%Jo%Murphy%Nyland.%%%%

! ! ! ! ! Notice'of'Privacy'Practices''!

800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!

!

This! notice! describes! how!medical! information! about! you!may! be! used! and! disclosed! and! how! you!may! have!access!to!this!information.!Please!review!this!carefully.!!!Who!Will!Follow!These!Practices?!

• Protected!Health!Information!(PHI)!will!be!disclosed!by!CEPT!and!therapists.!!• These!policies!do!not! apply! to! information! that!CEPT!and! therapists! receive!while! in! a!nonFhealth! care!

provider!capacity.!• These! require!CEPT,! employees,! and!any! third!parties! that!participate! to! comply!with! the!privacy! rules!

while!engaging!in!activities.!!• CEPT!employees!providing!services!are!required!to!protect!each!patient’s!PHI.!This!is!information!we!have!

created! or! received! relating! to! health! conditions,! all! of! the! health! care! payments! that! identify! you! or!provides!basis!to!believe!the!information!can!identify!you.!!

• PHI! does! not! include! individually! identifiable! information! contained! in! the! Family! Education!Rights! and!Privacy!Act!and!the!Health!Insurance!Portability!and!Accountability!Act!(HIPAA).!

• We!provide!you!with!this!notice!to!explain!how,!when,!and!why!we!disclose!your!PHI.!We!will!not!disclose!any!more!than!is!necessary.!!

• We!reserve! the! right! to!change! the! terms!of! this!notice!at!any! time! that!will! apply! to!what!we!already!have.!We!will!make!the!change!in!this!notice!and!post!a!new!one!at!CEPT!locations!and!on!the!website.!!

!How!We!May!Disclose!and!Use!Your!Protected!Health!Information!

• Certain!Uses!and!Disclosures!Do!Not!Require!Your!Authorization!for!These!Reasons:!o For'Treatment—!It!may!also!be!disclosed!to!educational!facilities,!your!referring!physician,!and!

those!participating!in!the!delivery!of!health!care.!!o For'Payment—It!may!be!disclosed!so!your!services!are!billed!and!payment!is!collected!properly.!

We!may!tell!the!clinic!about!treatment!to!be!received!to!obtain!prior!approval!and!determine!if!your!plan!covers!treatment.!We!may!discuss!PHI!with!a!pharmacist!as!well!to!determine!correct!dosage!and!administration!of!medical!information.!!

o For'Health'Care'Operations—It!may!be!disclosed!to!review!services!to!evaluate!the!performance!of!the!staff!and!make!sure!all!patients!receive!quality!care.!We!may!combine!the!PHI!of!several!patients! to!determine! if!additional!services!need!to!be!offered,!which!services!are!not!needed,!and! if! treatments! are! effective.! Identifiable! information! may! be! removed! for! educational!facilities!to!use.!!!

o When' Disclosure' Is' Required' By' Law—Under! HIPAA,! we! must! make! PHI! disclosures! to! the!Secretary!of!the!Department!of!Health!and!Human!Services!if!the!law!requires!us!to!do!so.!It! is!for!them!to!investigate!our!compliance!with!the!requirements!of!the!Privacy!Rule!with!HIPAA.!!

o For'Public'Health'Activities—It!may!be!disclosed!if!information!is!reported!about!births,!deaths,!various!diseases,!etc.!to!government!officials!collecting!this!information.!Information!will!also!be!provided!to!necessary!medical!providers.!!

o For'Health'Oversight'Activities—It!may!be!disclosed! to!a!health!oversight!agency! for!activities!authorized! by! the! law.! This! is! necessary! to! assist! government! conduction! of! investigation! or!inspection!of!a!health!care!provider!or!organization.!!

o For' Research' Purposes—It! may! be! disclosed! to! approved! researchers! with! reviewed! and!accepted!protocols.!This!will!include!no!unique!identification!of!the!subject!of!the!information.!!

o To'Avoid'Harm—It!may!be!disclosed!when!we!believe! it!will!prevent!a!serious!threat!to!health!and!safety!of!a!person!or!the!public.!We!may!provide!PHI!to!law!enforcement!able!to!prevent!or!lessen!harm.!

! ! ! ! ! Notice'of'Privacy'Practices''!


!

o For' Specific' Government' Function—It!may! be! disclosed! for!military! personnel! or! veterans! for!intelligence,!counterintelligence,!and!national!security!purposes.!!

o For' Workers' Compensation' Purposes—It! may! be! disclosed! to! comply! with! these! laws! that!benefit!workFrelated!injuries!or!illnesses.!!

o Appointment'Reminders' and'HealthJRelated'Benefits—It!may!be!disclosed! for! reminders! and!give!information!about!treatment!alternatives!or!services!we!offer.!!

o Inmates—It! may! be! disclosed! about! an! inmate! or! the! person! having! lawful! custody.! This! is!necessary! to! provide! them! with! health! care,! protect! their! and! others! health! and! safety,! and!provide!law!enforcement!on!institution!premises.!!

o To'You'or'Your'Personal'Representative—It!may!be!disclosed!to!your!representative!if!you!are!a!minor.!We!will!obtain!documentation!that!supports!your!representation!prior!to!disclosure.!We!do!have!the!right!not!to!accept!this!person!if!we!have!reason!to!believe!they!are!a!danger!to!you!in!some!form.!!

• Uses!and!Disclosures!with!Prior!Written!Authorization:!o In!situations!not!referenced!above,!we!will!as!for!written!authorization!before!using!or!disclosing!

your! PHI.! If! you! choose! to! authorize! PHI! disclosure,! you! can! later! revoke! the! authorization! in!writing!to!stop!any!further!disclosure.!!

!What!Rights!You!Have!Regarding!Your!PHI!

• To'See'and'Get'Copies'of'Your'PHI—The! request!must!be!made! in!writing!and!we!will! respond! to!you!within!30!days!of!receiving!it.!We!may!deny!the!request!in!writing!in!certain!situation.!We!may!also!charge!a!fee!for!copying,!mailing,!or!supply!costs.!!

• To'Correct'or'Update'Your'PHI—If!you!think!there!may!be!a!mistake!or!information!is!missing,!you!may!submit!a!request!in!writing!to!change!it!and!we!will!respond!to!it!within!60!days.!We!may!deny!it!if!the!PHI!is!complete!and!correct,!not!created!by!us,!not!allowed!to!be!disclosed,!or!is!not!part!of!our!records.!If!we!approve!it,!we!will!make!the!change,!tell!you!that!we!have,!and!make!sure!others!know!!

• To'Get'a'List'of'the'Disclosures'We'Have'Made—We!will!respond!within!60!days!of!your!written!request.!This!list!will!include!disclosures!made!in!the!last!6!years!unless!you!request!a!shorter!time.!It!includes!the!date!of!disclosure,!to!whom!it!was!disclosed,!description!of!the!information,!and!the!reason!for!disclosure.!

• To'Request'Limits'on'Uses'and'Disclosures'of'Your'PHI—A!written!request!must!be!submitted!to!CEPT.!It!must! tell! us! the! PHI! you!would! like! to! limit,! the! reasons! why,! and! to! whom! the! limits! apply.!We!will!consider!this!request!but!are!not!legally!required!to!accept!it.!!

• To'Choose'How'We'Send'PHI'To'You—You!can!request!that!we!send!information!to!an!alternate!address!or!by!alternate!means.!We!must!agree!to!this!request!as!long!as!it!is!reasonable!and!can!easily!provide!the!requested!information.!It!must!be!submitted!in!writing!to!CEPT.!!

• To'Get'a'Paper'Copy'of'this'Privacy'Notice—Request!must!be!submitted!or!you!may!look!on!our!website!for!a!copy!at!www.cuttingedgepediatrictherapy.com!!

!How!to!Complain!About!Our!Privacy!Practices!

• If!you!think!we!may!have!violated!your!privacy!rights!or!you!disagree!with!a!decision!made!about!access!to!your!PHI,!you!may!file!a!complaint!with!the!CEPT!Privacy!Officer.!!

o We!will!take!no!retaliatory!action!against!you!if!you!file!a!complaint!about!our!Privacy!Practices.!!____________________________________________!!!!!!___________________________________________!Signature!of!Patient!or!Personal!Representative! ! ! Date!

! !!!!!!

Financial!Agreement!!

!!800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! !!21703!Kingsland!Blvd.,!Ste.!100!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!Katy,!TX!77450!

Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!

!BlueCross!BlueShield,!United!Healthcare,!Aetna,!and!Cigna!Insurance!Companies!Cutting! Edge! Pediatric! Therapy! is! an! inFnetwork! provider! with! Blue! Cross! Blue! Shield! (BCBS)! and! files! outFofFnetwork!insurance!claims!with!United!Healthcare!(UHC),!Aetna,!and!Cigna!Insurance!companies.!Please!notify!us!if!your!insurance!company!is!not!listed!and!we!will!research!our!ability!to!file!your!claims!and!provide!treatment!under!your!insurance!plan.!!!Patients!are!billed!for!their!annual!outFofFnetwork!deductible!at!the!beginning!of!their!plan’s!calendar!year.!After!the!patient’s!outFofFnetwork!deductible!has!been!satisfied,!the!patient!is!responsible!for!the!coFpay!amount!set!by! their! insurance!carrier.!Patients!are!billed! for! the! remaining!balance!after!payment!has!been! received! from!their!insurance!company.!Any!nonFcovered!services!are!the!financial!responsibility!of!the!patient.!!!!In! the! event! that! payment! for! a! performed! service! is! denied! by! the! insurance! carrier,! it! is! the! patient’s!responsibility!to!pursue!action!with!their!insurance!carrier,!as!the!policy!is!a!legal!contract!between!the!patient!and!the!insurance!company.!If!the!insurance!company!does!not!pay!claims!within!60!days!for!any!reason,!I!will!be! responsible! for! payments! to! Cutting! Edge.! If! I! do! not! honor! this! financial! agreement! and! develop! an!outstanding!balance,! I!will! pay! the! charges!within!30!days.! I! agree! to! an! interest! charge!of! 1.5%!per!month!(18%! per! year)! if! my! balance! is! not! paid! within! 30! days.! If! payment! is! not! made,! I! waive! the! right! to!confidentiality!for!the!purpose!of!collection!of!the!said!fee.!Any!reasonable!attorney!fees!and!costs!incurred!by!Cutting!Edge!Pediatric!Therapy!for!the!collection!of!the!past!due!account!shall!be!my!obligation!as!well.!!For!Other!Carriers,!There!is!no!Insurance!Coverage:!If!a!patient!has!insurance!carriers!other!than!BCBS,!UHC,!Cigna!or!Aetna!or!has!no!insurance!coverage,!they!are!responsible! for! all! charges! incurred! at! the! time! of! service.! ! CoFpayments,! coFinsurance,! nonFcovered! services!and/or!deductibles!are!the!responsibility!of!the!patient!and!are!payable!at!the!time!of!service.!!BY! SIGNING!THIS!DOCUMENT,! I!UNDERSTAND!THAT!PAYMENT! IS! EXPECTED!AT!THE!TIME!OF!SERVICE.! I!MUST!PROVIDE!A!PHOTO!COPY!OF!MY!INSURANCE!CARD!ANNUALLY!AND!ANY!TIME!THAT!I!CHANGE!INSURANCE!PLANS.!!IT!IS!MY!RESPONSIBILITY!TO!NOTIFY!CEPT!OF!ANY!CHANGES.!!I!UNDERSTAND!THAT!I!MAY!BE!RESPONSIBLE!FOR!ANY! AMOUNT! NOT! COVERED! BY!MY! HEALTH! PLAN!WITHOUT! LIMITATION! OF! THE! OUTFOFFNETWORK! OR! INFNETWORK!DEDUCTIBLE,!COFPAYMENT!AND/OR!COINSURANCE!AMOUNT.!!!!!If!your!insurance!policy!has!visit!caps!or!limited!visits,!it!is!your!responsibility!to!track!these!visits!as!they!occur.!If!you!have!participated! in!occupational! therapy!visits!with!another!provider!during! the! insurance!year,! then!you!will!need! to! include! those!visits.!CEPT!will!attempt! to! track! these!visits,!however,!you!as! the!customer! receive!more!timely!information!from!your!insurance!provider.!!!!____________________________________________ __________________________________________ !Parent/Legal!Guardian!Signature! ! ! Date!! ____________________________________________ __________________________________________! !!Patient’s!Name!! ! ! ! ! Date!of!Birth!! ____________________________________________ __________________________________________ !HIPAA!Privacy!Officer! ! ! ! ! Date

!!!!!!!Communication*Consent*Form**

!!!800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! !!21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!

I! give! permission! to! CEPT! to! contact! me! in! the! following! methods! regarding! my! private! health!information,!evaluation,!treatment,!and!appointments.!I!authorize!CEPT!to!leave!messages!for!me!when!I!am!unavailable.!You!will!receive!an!email!or!text!three!days!prior!to!your!appointment!as!a!reminder.!If!you!are!not!receiving!this!or!in!the!correct!amount!of!time,!please!let!us!know.! ! ! ! !!!!!!!!!!Home!Phone!!!!!(______)!____________________! ! !!

! !!! Message!with!Information!! ! !Message!with!callFback!number!only!!! !

!!!!!!!!Cell!Phone!!!!!!!!!(______)!____________________!!

! ! Message!with!Information! ! !Message!with!callFback!number!only!!!! !

!!!!!!!!Work!Phone!!!!!!(______)!____________________!!

! ! Message!with!Information! ! !Message!with!callFback!number!only!!! !

!!!!!!!!Text!Messages!!(______)!____________________!!

! ! Message!with!Information!! ! !Message!with!callFback!number!only!!! !

!!!!!!!!Email!!!!!!!!!!!!!!!!!!!______________________________________!!

! ! Message!with!Information!! ! !Message!with!callFback!number!only!!!I!authorize!CEPT!and!therapists!to!discuss!my!health!care!information!with!the!contacts! listed!below.* I!understand!that!by!leaving!these!spaces!blank,!I!am!indicating!that!I!do!not!want!information!released!to!anyone!else.!*!!Name** * * * Relationship*to*Patient*** * * Phone*Number*____________________________________________________________________________________**____________________________________________________________________________________**By!signing,!I!acknowledge!that!I!have!read!and!understand!these!communication!guidelines.!I!allow!CEPT!to!contact!me!by!these!means!and!give!permission!to!the!people!listed!above!to!receive!patient!health!care!information.!!!!_________________________________________! _____________________________________!Patient,!Guardian,!Legal!Representative!Signature! Date!!

!!!!!!!!!!Clinic!Wellness!Policy!!!800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!!

!

Please! do! not! bring! your! child! (patient! or! sibling)! into! the! Clinic! if! they! are! exhibiting! any! of! the! following!medical!health!concerns:!!!!!Fever:!Fevers!are!common!in!young!children!and!are!often!a!signal!that!something!is!wrong.!!If!your!child!has!a!fever!of!101.0F!or!higher,!please!keep!him/her!at!home.! ! If!you!child!develops!a!fever!of!101.0F!or!higher!while!at!the!Clinic,! the! therapy! session! will! end! and! your! therapist! will! make! every! reasonable! effort! to! reschedule! the!appointment.!!Our!policy!is!that!your!child!must!remain!feverFfree!for!24!hours!before!returning!to!the!Clinic,!a!policy!agreed!upon!by!local!pediatricians.!!The!24!hours!begins!when!your!child’s!fever!has!broken!and!remains!in!the!normal!range.!!Diarrhea:!!Diarrhea! due! to! illness! is! highly! contagious.! ! If! your! child! has! diarrhea,! please! keep! him/her! home.! ! Please!understand!that!germs!from!diarrhea!can!spread!throughout!carpet,!toys,!swings!and!direct!contact.! !It! is!very!difficult!to!keep!these!germs!from!spreading!to!other!children.!!However,!if!this!is!a!chronic!condition!for!your!child,!please!advise!your!therapist!so!that!we!can!make!the!appropriate!recommendations!or!accommodations.!!!!!Vomiting:!If!your!child!vomits!while!at!the!Clinic,!you!will!be!called!to!pick!him/her!up!immediately.!!Please!keep!your!child!at!home!for!24!hours!after!the!vomiting!has!stopped.!!When!children!return!to!therapy!prematurely,!there!is!a!much!higher!rate!of!recurrence!and!contagiousness.!!Severe!Common!Cold:!Symptoms! include,!but!are!not! limited!to:! !bad!cold!with!a!hacking!or!persistent!cough;!green!or!yellow!nasal!drainage;! and/or! a! productive! cough!with! green! or! yellow! phlegm.! These! symptoms!may! be! present!with! or!without!a!fever.!!Seasonal!allergies!are!exempt!from!this!policy.!!Rash:!A!rash!may!be!a!sign!of!many!illnesses!such!as!measles!or!chicken!pox.!!Please!do!not!bring!your!child!into!the!clinic!until!your!doctor!releases!you!to!do!so.! !Rashes!due!to!nonFcontagious!skin!conditions!are!exempt!from!this!policy.!!!!!We!do!understand!and!empathize!with!parents!when!their!children!are!ill.!!These!policies!are!designed!to!be!fair!to!the!ill!child!and!their!family,!as!well!as!the!healthy!children!and!their!families.!!Please!understand!that!we!love!your!children!and!strive! to! provide! the! best! possible! care! for! them.! !We! hope! to! control! the! amount! of! illness! at! the! Clinic! and! to! keep!everyone!healthy!and!happy.!!If!you!have!any!questions!or!concerns,!please!do!not!hesitate!to!call!us.!!Thank!you!!!____________________________________________! !!Printed!Patient’s!Name! ! ! ! ! !!____________________________________________! !__________________________________________!Printed!Parent/Guardian!Name! ! ! ! !Date!

Automatic)Credit)Card)Billing)Agreement))

!!

!!800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! !!21703!Kingsland!Blvd.,!Ste.!100!!!!!!!!!!!!!!!!Allen,!TX!75013! ! ! !!!!! ! ! ! ! ! ! Katy,!TX!77450!Tel:!(469)!675F3153!!!!!Fax:!(469)!675F3154!!!!! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!Tel:!(281)!769F1015!!!!!Fax:!(281)!717F8947!!!!!!!!!Email:[email protected]! ! ! ! ! ! ! ! !!!!!Email:[email protected]!

CUTTING! EDGE! PEDIATRIC! THERAPY! (CEPT)! can! process! your! payment! via! MasterCard,! Visa,! Discover,! and!American!Express!(credit!or!debit)!and!personal!checks.!!!Payment! is! due! upon! receipt! of! your! invoice! at! the! end! of! each! treatment!week.! Please! keep! a! copy! of! your!invoice! for! your! records.!You!may!choose! to!have!us! charge!your! credit! card!automatically!at! the!end!of!each!week! for! which! services! are! rendered! by! completing! the! authorization! form! below.! Should! you! choose! to!discontinue!the!automatic!credit!card!service,!it!is!your!responsibility!to!notify!the!business!office!in!writing.!!!!!At!CEPT,!we!work!diligently!to!protect!your!privacy.!Therefore,!this!document!will!remain!in!the!business!office!and!will!not!be!accessible!to!your!therapist.! If!you!need!to!make!changes,!please!contact!the!business!office!at!469F675F3153!(Allen),!281F769F1015!(Katy).!Thank!you!in!advance!for!your!consideration.!))Name!of!Patient:!__________________________________________________)!I! authorize!CEPT! to! charge!my! credit! card!weekly! for! therapy! services! rendered.! ! (A!$40! fee!will! be! charged! for!inactive/declined!credit!cards.)!!!Please)note:)A)copy)of)your)credit)card)will)be)needed)to)have)on)file.)))Name!of!Cardholder!as!it!appears!on!the!card:!______________________________________________________!

Card!Type:!!! !!!!!!!MasterCard!!!!!!!!!!!!!!!!!!!!!Visa! ! !!!!!!!Discover!!!!!!!!!!! American!Express!

Credit!Card!#:!!!!!!!!!(Please!print!clearly.)!

!!!! ! ! !!!! !!!!!!

!

Expiration!Date:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Security#!(last!3!digits!of!card)!!!

Cardholder’s!Billing!Address:!!____________________________________________________________________!

City______________________________________!State!_______________________Zip!Code________________!

_____________________________________________________! _________________________________!Cardholder/Responsible!Party’s!Signature! ! ! ! Date!!For!Office!Use!Only:!Date!Business!Office!Received!forms:!_____________________Received!by:!______________________________________! !

ClinicPolicies800N.WattersRd.,Ste.150 21703KingslandBlvd.,Ste.100

Allen,TX75013 Katy,TX77450Tel:(469)675-3153Fax:(469)675-3154 Tel:(281)769-1015Fax:(281)717-8947Email:[email protected] Email:[email protected]

Pleasereadandsignthefollowingpolicies.Keeponecopyofthisdocumentforyourrecordsandreturnacopytotheofficetobekeptinyourpatientfile.MissionStatement“TherapywithaPurpose.” CuttingEdgePediatricTherapy isdedicatedtoprovidingclientswiththehighestqualitytherapyservices.OurCliniciscommittedtohelpingourclientsachievetheirmaximumleveloffunctionbyprovidingcomprehensive, community-based rehabilitation services which are an integral part of the total rehabilitationcontinuum.TreatmentSessionsHalf hour sessions of therapy are equal to twenty-five (25)minutes of therapy. Forty-fiveminute (45) sessions oftherapyareequaltoforty(40)minutesoftherapy.Onehoursessionsoftherapyareequaltofifty-five(55)minutesoftherapy. The last 5-10minutes of the sessions are dedicated to discussing the treatment sessionwith the parent.___________(Initials)PaymentsandBillingPaymentforserviceisdueatthelastsessionofeachweekwhenservicesarerendered.Theindividualwhobringsthepatienttotherapyisresponsibleforpaymentofthetherapysession.PleasemakeallcheckspayabletoCUTTINGEDGEPEDIATRIC THERAPY. An Automatic Credit Card Billing Agreement form must be completed in order to chargetreatmentsessionstoyourcreditcard.Copiesofthecreditcardandtheparent/guardian’sdriver’slicensemustbeonfilewith thecompletedAutomaticCreditCardBillingAgreement. Pleasenote, therewillbea$40.00charge forallreturnedchecksanddeniedcreditcards.Theinvoiceprovidedatthetimeofserviceisyourreceipt.Statementsandreceiptsareprovideduponrequestonly.___________(Initials)Scheduling/ParticipationInorderforyourchildtoreachhis/herestablishedgoalsintheirtreatmentplan,itisimperativethatyourchildattendhis/her regularly scheduled visit. We at CEPT ask you to be mindful of this. We are aware that unanticipatedemergencies (e.g. illness, vacations) take place. However, your child needs as much consistency as possible. Werequireourchildrentomaintaina75%attendancerateattheirregularlyscheduledtimeinorderforthemtocontinuetomakeprogress. If appointmentsarenotmaintainedona consistentbasis,wemayhave tomoveyour child toadifferenttreatmenttime._______(Initials)NoShows,LateCancellationsOur professional standard is to begin and end each session in a timelymanner. Therefore, our expectation of ourclientsisthattheywillbepunctualsothatweareoptimizingourappointmentstothepatient’sbenefit.Appointmentsfollow a specific treatment plan for each patient. As such, patient’s arriving more than 10 minutes late may berescheduledandchargedalatecancellationfee.Patientsarrivingmorethan15minuteslateareconsideredNoShowsunlessotherarrangementshavebeenmade.Certainlyweunderstandthatthereareexceptionstothispolicy,suchassick children and family emergencies, which are not possible to control.We simply ask that you be asmindful aspossibleofyourtherapist’sschedule.Pleasenotethatitisyourresponsibilitytocontactthetherapistthatworkswithyour childas soonaspossible inorder toeliminateanyextra fees. Youmayalso contact thebusinessofficeat thenumber above and leave a message after hours, or email the office directly at [email protected] (Allen),[email protected](Katy).___________(Initials)

ClinicPolicies800N.WattersRd.,Ste.150 21703KingslandBlvd.,Ste.100Allen,TX75013 Katy,TX77450Tel:(469)675-3153Fax:(469)675-3154 Tel:(281)769-1015Fax:(281)717-8947Email:[email protected] Email:[email protected]

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NoShows:AppointmentsthatarenotcancelledareconsideredaNoShow.Patientsarrivingmorethan15minuteslatefortheirscheduledappointmentareconsideredNoShows.NoShowappointmentsarechargedthefullrateofthescheduledtherapysession.___________(Initials)LateCancellations:Werequest24hoursnoticeforacancelledappointmentinorderforourtherapiststohavetheopportunitytoadjusttheirscheduleaccordingly.Anappointmentthatisnotcancelledatleast2hourspriortothescheduledappointmenttime is considered a late cancellation and clients will be charged a fee that equals half of the scheduled therapysession.___________(Initials)LatePatientPick-Up:Thelatepick-upfeeis$36.00forevery15minutes.CEPTcannotaccommodatechildrenthatareleftunattendedasourtherapistsmustgoontothenextscheduledappointment. Ifyou leavetheclinicduringthepatient’ssession,pleasereturnfiveminutespriortotheconclusionofthesession.Wearemindfulofthosecircumstancesthatareunavoidable.If an emergency occurs, please contact the business office as soon as possible so that the CEPT staff can makeaccommodationsforthepatient.___________(Initials)SaturdayAppointmentsTheseappointmentsareverylimitedandverydesirableamongourpatients.PleaseunderstandthisifyouarechoosingtocommittoapermanentSaturdayspot.PatientsareonlyallowedtomissthreeSaturdayappointmentsperyearduetoillness,vacation,etc.Ifmorethanthreedayshavebeenmissedinashortperiodoftime,youwillbeaskedtofindadifferentappointmentspotduringtheweek.This isamedically-basedclinic,soweaskthatyoubemindfulofthiswhenschedulingyourappointment.___________(Initials)NoticetoDiscontinueTreatmentIfyouchoosetodiscontinuetherapyservices,youwillneedtoprovide30daysnoticepriortoyourlastsession.CEPTiswilling toaccommodate twoweekpriornotice forunique circumstanceswhichwill bedeterminedonan individualbasis.Ifyouchoosetodiscontinueservicesbeforeclinicallyindicated,werequirenoticeinordertoallowappropriatetermination of services including but not limited to: allowing time for any retesting that may be necessary tosummarizethechild’sprogramandprogress,provideahomeprogramspecifictotheneedsofthechild,andadequatetime to compiledocumentation for referral and reimbursementproviders.Cancellationof therapy servicesmustbereceived inwriting (verbal cancellationswillnotbeaccepted). If thepropernotice isnotprovided,youwillbeheldfinanciallyaccountableforuptofourweeksoftherapyservicesatthefullrateifnotcoveredbyyourinsurancecarrier._________(Initials)HOLDPolicyItisforthebenefitofthepatientthattheyreceiveconsistenttreatmentandarepresentfortheirscheduledtherapysessions.We understand that certain personal situations may require that the patient have a short absence fromtherapyservices.CEPT isabletoputyourchildonHOLDforamaximumoftwoweeksduringwhichtheirtreatmentfollowingtheabsenceissecured.IfthepatientisonHOLDforadurationgreaterthantwoweeks,thepatientwillthenbedischargedandfulltestingwillberequiredtoresumetreatment.AllrequeststobeputonHOLDmustbereceivedinwriting(verbalrequestswillnotbeaccepted)._________(Initials)

FeedingPolicyPatientswhoare involved in feedingappointments:Parentswillbe responsible forproviding thecorrect food itemsthat the therapist suggests for the patients. Therapists will not be responsible for providing food. If therapists doprovidefood,CEPTwillchargea$25.00monthlyfeetocoverexpenses.___________(Initials)ClinicandWaitingRoomMannersThecareandsafetyofchildrenand/orsiblingsthataccompanyyoutothepatient’ssessionareyourresponsibility.Inaddition,apatient’ssafetyistheresponsibilityoftheparentorguardianwhennotaccompaniedbyatherapist. Fortheirprotection,childrenarenotallowedinotherareasofthebuildingandarenotpermittedoutsideofthebuildingunlessescortedbyaparentorguardian.Children inthewaitingroomaretheresponsibilityoftheparentorguardian. Weaskthatyoupleasemonitoryourchild in thewaitingroomandrespect thepropertyofCEPTandtheother families in thereceptionarea. Wemakeeveryefforttokeepourwaitingroomcleanandtidy.Ifyoubringsnacksand/ordrinksintothewaitingroom,pleasekeeptheareacleanofanyspills.Wegreatlyappreciatetheuseofliddedcups.Pleasesuperviseyourchildrenintherestroom.Due toHIPAA regulations,we are not allowed to invite parents or guardians or siblings into the treatment areaunaccompaniedbyatherapistand/orifanotherpatientisbeingtreatedinthesamearea.

Thankyouinadvanceforyourcourtesy.___________(Initials)


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AuthorizationforEmergencyCareThis form is designed tomeet the legal requirements established inHB 1452, Acts of the 61st Legislature, RegularSession,whichprovidesthatanypersonwhohascustodyofaminormaygiveconsenttomedicalcareifthepersonhasasignedaffidavitbyoneorbothparentsauthorizingthepersontogiveconsent.Inorderthemeetalllegalrequirements;IherebyauthorizerepresentativesofCUTTINGEDGEPEDIATRICTHERAPYtogiveconsentforanynecessarymedicalcareformychild/childreninsaidindividual’scustody.___________(Initials)PatientReleaseforInternsandVolunteerStaffCEPT isateachingclinicsoonoccasionstudent interns fromvariouscollegesmayaccompanyyourchild’s therapist,observe treatments, and have sight of their notes. A background check through each respective institution isconductedforeachstudentintern.CEPTperiodicallyallowsvolunteerstoassistintheclinic.Theywillbeinthegymwith your child under the supervision of your child’s therapist. Each volunteer has HIPAA privacy instructions.Volunteersare inplace to learnandassist the therapist in the treatmentof thepatientandwork for thebenefitofpatient’s care. Volunteers are not employees of CEPT and cannot assist you with billing, scheduling, medical orinsuranceinformation.By signing, I understand thatmy child’s treatment, testing, evaluations, dailynotes and/or invoiceswill be seenbystudentinternsintrainingtobecomeOccupationalTherapistsandbyvolunteerstaff. Iunderstandthatthestudentinternsand/orvolunteerswillbeinvolvedinthetreatmentofmychild.___________(Initials)AdultPatientsIfthepatientis18oroveritisnecessarythatCuttingEdgePediatricTherapyreceiveeitherproofofguardianshiporpermission from the patient to share any details regarding evaluation or treatment (orally or through writtendocumentation) with parents or other family members. This is in reference to legal policy regarding privacylaws/confidentiality,inadditiontotheprivatepoliciesofCEPT.Iflegalguardianshipisnotprovided,thepatientmustfilloutandsignacommunicationconsentformpriortoanydiscussionofserviceswiththoseotherthanthepatient(verbalconsentwillnotbeacceptable).__________(Initials)Photo/Video/Website/PrintConsentI authorize CEPT to use my child’s photo(s) in our brochures, printed materials, and in the clinic, and my child’sphoto(s)and/orvideo(s)onourwebsitefortheuseofpublicrelations,promotingvariousCEPToccupationaltherapyprograms.IunderstandthatIwillbenotifiedbeforetheuseofthephoto(s)and/orvideo(s)._______YES(Initials)_______NO(Initials)TherapyDogConsentIauthorizeCEPTtouseatherapydogintherapysessionsaspartofmychild’streatment.Iunderstandthatmychildwillneverbeleftalonewiththetherapydog._______YES(Initials)_______NO(Initials)FinancialAgreementInsurancePolicy:

CuttingEdgePediatricTherapy (CEPT) isan in-networkproviderwithBlueCrossBlueShield (BCBS)and filesout-of-network insurance claims with United Healthcare (UHC), Aetna, Cigna, and Humana Insurance companies. Pleasenotify us if your insurance company is not listed and we will research our ability to file your claims and providetreatmentunderyourinsuranceplan.Patientsarebilledfortheirannualout-of-networkandin-networkdeductibleatthebeginningoftheirplan’scalendaryear. After the patient’s out-of-network deductible has been satisfied, the patient is responsible for the co-payamountsetbytheirinsurancecarrier.Patientsarebilledfortheremainingbalanceafterpaymenthasbeenreceivedfromtheirinsurancecompany.Anynon-coveredservicesarethefinancialresponsibilityofthepatient.


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Intheeventthatpaymentforaperformedserviceisdeniedbytheinsurancecarrier,itisthepatient’sresponsibilitytopursue actionwith their insurance carrier, as the policy is a legal contract between the patient and the insurancecompany.___________(Initials)TraditionalMedicaid:Medicaidparticipantsareexceptfromourinsurancepolicy.Ifyourchilddoesreceiveadditionalservices,pleasenotifyus immediately. The requirements in order to be accepted and maintained will be mandatory attendance andcancellationswithatleast24hournotice.Anynoshowswillresultinawarning.Anadditionalnoshowwillresultinthe discontinuation of the services. All sessions must be scheduled for a makeup within the same week to avoiddenials fromMedicaid.Weare required to reportyour failure tomakescheduledappointments toTexasMedicaid,whichcouldresultinalossofbenefits._______(Initials)Forothercarriers,thereisnoinsurancecoverage:If a patient has insurance carriers other than BCBS, UHC, Cigna or Aetna or has no insurance coverage, they areresponsible forall charges incurredat the timeof service. Co-payments, co-insurance,non-covered servicesand/ordeductiblesaretheresponsibilityofthepatientandarepayableatthetimeofservice.___________(Initials)VisitLimits:Visit limits are set by your insurance carrier. If your insurance policy has visit caps or limited visits, it is yourresponsibility to track these visits as they occur. If you have participated in any therapy services with anotherproviderduringtheinsuranceyear,thenyouwillneedtoincludethosevisits.CEPTwilldoourbesttokeeptrackofthesevisits,butitistheparent’sresponsibilitytomanagethevisitsoverall.Thisisespeciallyimportantifthechildisreceivingadditionalservicessuchasspeechtherapy,physicaltherapy,chiropracticcare,etc._______(Initials)JointCustodyPaymentPolicyCEPTcannotdividecreditcardpaymentsforchildrenofdivorcedparents. CEPT’spolicyrequiresthattheparentorguardianwhobringsthechildinforservicesbefinanciallyresponsibleforpaymentoftreatmentservicesunlessotherarrangementsaremade inadvancethroughthebusinessoffice. Parentsmaypayseparatelybycheckbutpaymentmustbemadeinfull.Forcreditcardpayments,onlythesignaturesofthecardholderspresentattheappointmentareallowed.Therearenoexceptionstothispolicy.___________(Initials)BYSIGNINGTHISDOCUMENT,IUNDERSTANDTHATPAYMENTISEXPECTEDATTHETIMEOFSERVICE.IMUSTPROVIDEAPHOTOCOPYOFMY INSURANCECARDANNUALLYANDANYTIMETHAT I CHANGE INSURANCEPLANS. IT ISMYRESPONSIBILITYTONOTIFYCEPTOFANYCHANGES.IUNDERSTANDTHATIMAYBERESPONSIBLEFORANYAMOUNTNOT COVERED BYMY HEALTH PLANWITHOUT LIMITATIONOF THE OUT-OF-NETWORK DEDUCTIBLE, CO-PAYMENTAND/ORCOINSURANCEAMOUNT.___________(Initials)

ClinicPolicies

800N.WattersRd.,Ste.150 21703KingslandBlvd.,Ste.100Allen,TX75013 Katy,TX77450Tel:(469)675-3153Fax:(469)675-3154 Tel:(281)769-1015Fax:(281)717-8947Email:[email protected] Email:[email protected]

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Yoursignaturebelowvalidatesyour initialsoneachoftheclinicpoliciesdescribedabove. Weappreciateyourtimeandeffortincompletingtheseforms.AccuratepatientdocumentationisnecessaryforCEPTtoprotectourpatients’rights.

800N.WattersRd.,Ste.150 21703KingslandBlvd.,Ste.100

Allen,TX75013 Katy,TX77450Tel:(469)675-3153Fax:(469)675-3154 Tel:(281)769-1015Fax:(281)717-8947

Email:[email protected] Email:[email protected] ____________________________________________ ____________________________________________ PatientName Parent/Guardian’sName____________________________________________ ____________________________________________Patient’sSignature(ifover18yearsofage) Parent/Guardian’sSignature____________________________________________ ____________________________________________ Date Date

!!!!!!!!!!!!!!!!!!!!!Authorization!To!Transfer!Medical!Records!!


!

!Patient!Name:!_______________________________________!Patient!ID!#:!______________________!!Date!of!Birth:!___________________!Gender:!___________!Social!Security!#:!_____________________!!Name!of!Therapist:!______________________________!Clinic!Location:!__________________________!!*I!hereby!authorize!Cutting!Edge!Pediatric!Therapy!to!release,!disclose,!and!deliver!the!following!information!to:!!!Name!of!Practice:!___________________________________!Provider:!__________________________!!Address:!_____________________________________________________________________________!!City!______________________________!State:!________________________!Zip!Code:!_____________!!Information! Requested:! I! authorize! the! release! of!medical! information! to! the! patient! above,! including! but! not!limited! to! the! categories! protected! by! state! or! federal! law:! a)! patient! treatment! notes,! b)! patient! testing! and!subsequent!written!evaluation!reports,!c)!patient!demographics.!!Redisclosure:! This! release! does! not! authorize! redisclosure! of! medical! information! beyond! the! limits! of! this!consent.! The! recipient! of! this! information! is! prohibited! from! using! the! information! for! other! than! the! stated!purpose,! and! from! disclosing! it! to! any! other! party.! A! general! authorization! for! the! release! of!medical! or! other!information!is!not!sufficient!for!this!purpose.!I!understand!and!agree!that!the!redisclosure!requirement!will!apply!to!these!records.!Federal!regulations!state!that!any!person!who!violates!any!provision!of!this!law!shall!be!fined!not!more!than!$500,!in!the!case!of!each!subsequent!offense.!!Validity:!I!understand!that!this!release!will!automatically!expire!one!year!from!the!date!of!my!signature,!and!that!I!may!revoke!this!release!by!sending!a!written!notice!to!the!person!or!entity!authorized!to!make!the!disclosure.! I!agree! that! any! release! that! has! been! made! prior! to! revocation! and! that! was! made! in! reliance! upon! this!authorization!shall!not!constitute!a!breach!of!my!rights!to!confidentiality.!!Facsimile!Transmission!of!Records:!The!records!may!be!faxed!to!the!authorized!recipient.!I!authorize!the!release!of!information!as!indicated!above.!!Partial!Medical!Record!for!this!Patient:!Please!specify!party!to!be!released!_______________________!!______________________________________! ! _______________________________________!Signature!of!Patient!! ! ! ! ! Date!(Or!if!under!18:!Parent,!Legal!Guardian,!Legal!Representative)!!______________________________________! ! _______________________________________!Printed!Name!! ! ! ! ! ! DL#! ! ! ! State!Issued!!!______________________________________! ! _______________________________________!Witness!! ! ! ! ! ! Date!!!!Release!By:!_______________________________________!Date!Released:!_______________________!

AdultPatientCommunicationAuthorization 800N.WattersRd.,Ste.150 21703KingslandBlvd.,Ste.100

Allen,TX75013 Katy,TX77450 Tel:(469)675-3153Fax:(469)675-3154 Tel:(281)769-1015Fax:(281)717-8947 Email:[email protected] Email:[email protected]

I,______________________________,(Name)givemyauthorizationtoshareinformationregardingmyevaluationandtreatmentreceivedatCuttingEdgePediatricTherapy(includingdocumentation)with___________________________________________________________________________(Names)

Iunderstandthetypeofinformationthatmaybedisclosedtotheabovenamedperson(s)________(Initials)

Thisauthorizationwillbeineffectuntildischarge_________(Initials)

IunderstandthatIcanaddorremoveauthorizationofanypersonatanytimeinwritingtoCuttingEdgePediatricTherapy___________(Initials)

Iunderstandthatauthorizingthedisclosureofthishealthinformationisvoluntary,andIdonotneedtosignthisformtobeeligibleforevaluation/treatment___________(Initials)

YoursignaturebelowvalidatesyourinitialsoneachcomponentoftheAdultPatientCommunicationAuthorizationForm.

_______________________________ __________________________

PatientPrintedName PatientDateofBirth

______________________________ __________________________

PatientSignature Date

Documents

Intake Introduction- Allen · 2016. 6. 28. · Patient!Intake!Form!!!!!*All!Fields!Required!!!! 800!N.!Watters!Rd.,!Ste.!150! ! !!!!! ! ! ! ! ! 21703!Kingsland!Blvd.,!Ste.!100!!!!!Allen,!TX!75013