New Client Intake Form

Name: Learning In Motion
Address: 306 Snug Harbor Road, Newport Beach, California, 92663, US
Telephone: +1-214-288-4503
Price range: $

Today's Date*
MM slash DD slash YYYY
Child's Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Address (if different from above)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Name*
First Last
Address (if different from above)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Work Phone*
Email*
Occupation/Employer*
Father's Name*
First Last
Address (if different from above)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Work Phone*
Email*
Occupation/Employer*
Child Lives With...*
Siblings (names and ages)*
Primary Care Physician
Primary Care Physician*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Name
Emergency Contact Name (not living with you)*
First Last
Relationship to Client*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hospital/Clinic Preference*
Allergies/Special Health Considerations*
Medical History
Current Concerns/Reason for Referral*
Referred By*
Past Illnesses, Injuries or Hospitalizations*
Current Diagnosis(es) if Any*
Medical Precautions and/or Limitations*
Ear Infections (frequency since birth)*
Tube Placement (when/which ear)*
Medications and Supplements (name, dosage, frequency)*
History of Seizure Disorder (type, medications)*
Allergies (foods, medications, environment, etc)*
Food Intolerances*
Dietary Restrictions*
Behavioral Difficulties (please describe)*
Family History of Developmental Delays or Learning Disabilities*
Educational History
Name of School/Preschool*
Teacher’s Name*
First Last
Grade*
Social/Academic strength(s)*
Social/Academic Difficulty*
How Does Your Child Interact With Others (cooperative, shy, friendly, aggressive)*
Does Your Child Receive Any Special Services at School? (please describe)*
How Does Your Child Do With Homework?*
Developmental History
Pregnancy and Birth*
Delivery ( vaginal / c-section ) Weeks of gestation*
Birth weight*
Complications during pregnancy or delivery? (please explain)*
Breastfed (how long)*
or Bottlefed*
Strong Suck*
- Yes
- No
Frequent spit-ups*
- Yes
- No
How many hours does your child sleep at night*
Does your child take napsor have other sleep issues*
Does your child wake frequently at night*
Does your child sleep in their own bedroom?*
Temperament as a baby:*
- Irritable
- Happy
- Quiet
DEVELOPMENTAL MILESTONES
Please note age (in months) when your child achieved the following skills:
Rolled over*
Sat unsupported*
Crawled on hands and knees*
Said first words*
Dressed independently*
Toilet trained:*
Crawled on hands and knees (Yes/No) and what age*
Walked*
Combined 2-3 words*
Finger fed*
Used spoon*
Drink from cup*
Managed snaps & buttons*
FEEDING AND ORAL MOTOR
Does your child demonstrate any of the following difficulties with feeding/oral motor skills:*
- Overstuffing Mouth with food
- Gags/vomits during feedings
- Frequently drools
- Picky food preferences
Limited Diet*
Special Diet*
Food texture preferences (i.e. soft, crunchy, warm, cold)*
History of Reflux ( Yes / No ) Explain*
What is a typical day of eating and drinking for your child?*
FINE MOTOR
Does your child have a hand preference: Left or Right*
Does your child use scissors and do they use them efficiently*
Do you notice frequent grasp changes when your child holds a pencil or tool*
Does your child break pencils easily or use very light pressure*
Does your child have any handwriting issues for his/her*
Does your child fatigue quickly with fine motor tasks*
Additional comments on fine motor skills*
SPEECH LANGUAGE
What is the primary language spoken in the home*
Does your child follow directions and respond to 1 step commands ( Yes / No ) Comments*
How does your child communicate wants/needs/ideas (gestures, single words, sentences)*
Do you feel your child can hear what you are saying*
- Yes
- No
Does your child respond when you call his/her name*
- Yes
- No
Do you have any concerns with your child’s sound production (difficult to under- stand, very few sounds, stuttering)*
- Yes
- No
What does your child do if he/she is not understood by others*
Is there a family history of speech/language disorders? If so, please list*
Additional Comments on Speech Language*
GROSS MOTOR
Does your child have difficulty in changing positions?*
Does your child get frustrated easily when trying to learn new motor tasks_*
Does/did your child tolerate tummy time?*
Does your child get to crawl or walk up and down stairs regularly ?*
Does/did your child walk on his/her toes?*
Does your child fall frequently by tripping or bumping into things*
How does your child handle daily routines, morning/bedtime routines?*
Are there any chores your child is required to do? How do they handle it?*
How much screen time per day and what type?_*
Additional Comments*
I understand that I will be receiving my child's evaluation report, progress reports and other information regarding his/her care at Learning in Motion via e-mail. I have listed the e-mail address to be used below.
E-mail address*
Parent Name*
First
Signature*
I acknowledge that the information that has been reported in this document is true and correct. I understand that failure to report comprehensive information regarding my child’s medical condition(s), diagnoses, and/or developmental history may compromise his/her ability to receive the appropriate therapeutic services.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
PARTICIPATION RELEASE
I (We) the undersigned parent(s) of*
, a minor, understand that participation in occupational therapy services may involve the use of suspended equipment, climbing equipment, and/or various other active play equipment. I (We) understand that this is an integral part of my child’s therapeutic process.
Furthermore, I (We) the undersigned parent(s) of*
a minor, do hereby release, discharge and hold harmless the staff at Learning in Motion from any and all claims and/or liability for personal injury, property damage, and claims of any nature or type arising out of my child’s attendance at and participation in any therapy session. This release is and shall be binding upon my heirs, assigns, executors, and administrators.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Printed Name*
First
I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Patient Name*
First
DOB*
MM slash DD slash YYYY
Consent for Bathroom Release
I hereby authorize Learning in Motion to allow my child to use the bathroom with staff assistance and supervision. If my child is not toilet trained, I authorize Learning in Mo- tion staff to provide diaper changing if required during the therapy session.
Initial*
Consent to Contact Physician
I hereby authorize Learning in Motion to contact my child’s physician in order to obtain a prescription for Occupational Therapy to treat my child.
Initial*
PHOTO/VIDEO RELEASE
I,*
Parent/Guardian of*
hereby authorize and consent to the use of his/her visual image by Learning In Motion for appropriate purposes, including but not limited to: still photography, video, electronic and print publications, and websites. I give this consent with no claim for payment
Signature*
Date*
MM slash DD slash YYYY
LEARNING IN MOTION POLICIES AND PROCEDURES
Learning in Motion is committed to providing you and your family with the professional services and timely information that you will need in order to progress in your therapy goals. We also need your commitment of consistent attendance and diligent effort to make our partnership a success. Please have your child to therapy on time so we can maximize the 60 minute treatment sessions, with 50 minutes of treatment and 10 min- utes of feedback following the session.
Please sign, date, and fill out every section below indicating you understand and agree to all of the below terms.
Attendance Policy: Therapy is most effective for your child with consistency. There- fore, regular attendance at all appointments is important. If THREE or more consecutive appointments are missed and not rescheduled, we are unable to hold the appointment time and it will be given to another person. If the regular appointment time is difficult to maintain, please discuss the possibility of a different time or day with the office. We cannot guarantee an appointment be held for an extended vacation.
Credit Card: Learning in Motion requires a valid credit card be kept on file for each client. The credit card on file will be charged monthly between the 5th and 10th of each month UNLESS ZELLE, VENMO, OR CHECK IS REQUESTED for payment format. Please let Tara MacKenzie at tara@learninginmotionoc.com know if you pre- fer a different payment format You will receive an email receipt with the amount charged to your credit card on file. FSA and HSA cards are acceptable with a “back-up” credit card on file.
INITIAL*
Cancellation Non-Emergent: All appointments must be cancelled within 24 hours of your scheduled appointment time by calling, texting, or emailing your therapist. We consider the following examples of NON-EMERGENT reasons to cancel an appoint- ment: vacations, pre-scheduled MD appointments, family events, parties, recreational events, after school activities, absentee babysitter, holiday weekend, school holiday, day before/after a holiday or a scheduling conflict. All appointments not cancelled within 24 hours of a scheduled appointment will be charged a late cancellation fee of $50.00 per appointment scheduled.
INITIAL*
Emergency Cancellation: In the event of an emergency, such as a sudden illness, death in the family, hospitalization, emergency MD visit; please make every effort to contact your therapist as soon as possible prior to your scheduled appointment.
Sickness: Please notify your therapist by 7am the day of your scheduled appointment to avoid the late fee. We understand your child may get sick sometime throughout the day.
NO SHOW Appointments: NO SHOW appointments will bee charged a NO SHOW FEE of $50.00.
INITIAL*
Discontinuing Therapy: Should you need/want to discontinue therapy for any reason, Learning in Motion asks you to provide written notice via email or mail, 2 sessions in advance. This will give your therapist time to begin their discharge discussion and note/ report. Please note, you will be responsible for any, and all outstanding balances on your account at the time of discharge.
By Signing Below, I acknowledge I have read and agree with the revised Policies and Procedures for Learning in Motion. I acknowledge and agree to give Learning in Mo- tion, permission to charge my credit card on file for balances due for services rendered.
Parent/Credit Card Holder’s Signature*
Date*
MM slash DD slash YYYY
******It is required to have a credit card on file Learning in Motion, so please fill out the below in order to keep for our records.
Name as it appears on credit card*
First
Credit Card #*
CVC#*
Zip Code*
ZIP / Postal Code
Child's Name*
First
Email*
INSURANCE BILLING
Learning in Motion is happy to provide invoices with appropriate coding for our patients; however, we DO NOT file with insurance directly. Learning In Motion is out of network and does not bill directly with insurance. If any extra filing of insurance paperwork (be-yond the scope of monthly super bills) is needed to help facilitate reimbursement for a patient, there will be an extra fee of $75 per hour.
Parent Signature*
Date*
MM slash DD slash YYYY
Learning in Motion HIPAA NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. !Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and re- lated health care services.
Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.
Healthcare Operations: We may use or disclose, as needed, your protected health in- formation in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.
Your Rights: Following is a statement of your rights with respect to your protected health information.-You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.You have the right to request to receive confidential communications from us by alter- native means or at an alternative location. -You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact with your complaint. We will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information.I, hereby acknowledge, that I have read and agree to the above Privacy Practices as out- lined above by Learning in Motion.
Child's/Patient's name*
First
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY

New Client Intake Form

Primary Care Physician

Emergency Contact Name

Medical History

Educational History

Developmental History

DEVELOPMENTAL MILESTONES

FEEDING AND ORAL MOTOR

FINE MOTOR

SPEECH LANGUAGE

GROSS MOTOR

PARTICIPATION RELEASE

Consent for Bathroom Release

Consent to Contact Physician

PHOTO/VIDEO RELEASE

LEARNING IN MOTION POLICIES AND PROCEDURES

INSURANCE BILLING

Learning in Motion HIPAA NOTICE OF PRIVACY PRACTICES