Intake FormPersonal InformationFirst Name *Middle NameLast Name *Date of Birth *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year2123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000PrefixMr.Mrs.Ms.Mx.MissDr.Prof.Parent's First Name *Parent's Middle InitialParent's Last Name *Street Address *Apartment, suite, etcCityZIP / Postal Code *Email Address *Parent/Guardian is Emergency Contact?YesNoPhone *Communication PreferenceCallTextEmailPreferred AvailabilitySelect all the options that fit your schedule *Mondays - morningMondays - after lunchMondays - before dinnerTuesdays - morningTuesdays - after lunchTuesdays - before dinnerWednesdays - morningWednesdays - after lunchWednesdays - before dinnerThursdays - morningThursdays - after lunchThursdays - before dinnerFridays - morningFridays - after lunchFridays - before dinnerDrop-down for mornings (8am-noon), after lunch (noon-3pm) & before dinner (3-6pm)Location Preferred *HomeChildcareOther addressMEDICAL/INSURANCE INFOOther TherapiesPTSLPABAOtherPlease note any other services your child receivesNC Infant-Toddler Program *YesNoIs your child enrolled in the NC-ITP?Primary Care Practice *Primary Physician *Primary Care Phone *Primary Care Fax *New Medical InformationMedicaid Card#Managed Care ProviderPrimary Insurance CompanyGroup #Policy #Effective DateSecondary Insurance CompanyGroup #Policy #Effective DateFinancial ResponsibilityBy completing this form, I am confirming that I am financially responsible for all verifiable account balances.Financial ResponsibilityFinancially Responsible Party *ConsentConsentConsent For Treatment/Release of Medical Information *Consent for Treatment: Parent/guardian signature below provides consent for Company to provide occupational therapy evaluation and/or treatment as deemed necessary during care. I understand that treatment and recommendations are made based on necessary clinical judgment, and should additional referrals be needed or suggested, that I will be informed of those recommendations. Patient Communication: Parent/guardian signature provides consent for Company to communicate through secure email, text message, and phone call to communicate timely reminders and therapy updates as appropriate. Release of Information: Parent/guardian signature provides consent to Company to disclose or exchange any or all parts od medical records, such as medical history, evaluations, progress notes and treatment plans, with the child's last insurance company, primary care physician, Children's Developmental Services Agency, if applicable, and any additional listed provider, specialist, or caregiver as identified by the signing parent/guardian.Entity/ProviderPhone #Fax #Family member/CaregiverPhone #Relationship to childPatient Rights & ResponsibiltiesI understand I have the right to the following: * Revoke this authorization by sending written notice to this office and that this revocation will not affect this office's previous reliance on the uses or disclosures pursuant to this authorization * Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization * Inspect a copy of Patient Health Information being used or disclosed under federal law. Health care information will be released only upon written authority of the patient or responsible party or in accordance with federal and state laws * Refuse to sign this authorization * Receive a copy of this authorization * Restrict what is disclosed in this authorizationPermission to PhotographI give Locus Family Centered Therapies ("Company") permission to photograph my child for the following purposes: (Type of use/ Permission for each below. Please check where appropriate.)Photography/VideoDisplay still photos on Company website and/or social media (first name only)YesNoUse still photos in promotional materialsYesNoUse photos for documenting progress/ change in conditionYesNoDisplay videos on Company website and/or social media (first name only)YesNoUse videos for documenting progress/ change in conditionYesNoUse videos for staff/fieldwork education and mentoringYesNoPolicy/AcknowledgementCancellation PolicyWhen a family cancels or misses a scheduled appointment, they prevent another family from being seen. Frequently missed appointments can also affect developmental goal attainment. Please review the cancellation policy below and confirm that you agree to these guidelines. If two (2) or more scheduled sessions are missed or canceled within a thirty (30) day period, the following procedure will be put into place: - First warning: You will receive an email or letter stating that you are at risk of being discharged from care. You will also receive courtesy appointment reminders. - Second warning: If you continue to cancel or miss appointments without reasonable cause you will be discharged from Company-provided care. - Missed sessions should be rescheduled with your practitioner within 7 days. A missed or canceled session is considered excusable if you or your child is seriously ill, hospitalized, or injured. Previously scheduled travel or vacation time should be communicated at least 14 days in advance when possible, with a plan in place to hold makeup sessions prior to or afterwards. Thank you for your understanding. It is a privilege to work with you and your family!AcknowledgementI have read this information and have the right to a copy for personal records. I understand the information, acknowledge that I am the responsible party to consent for the patient and acting on behalf of the patient, have provided the most current information for the financially responsible party, and confirm that the information listed is accurate and up to date. I hereby verify my consent to the above stated information and terms. This consent is effective for a period of one year from the date it is signed.Parent/Guardian Name *Relationship to child *Child's Legal Name *Signature DateMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Send MessageSave as DraftPlease do not fill in this field.
