CLIENT INTAKE
CLIENT INTAKE
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Email *
Child's Name:
Child's DOB:
MM
/
DD
/
YYYY
Parent's Name
Address:
Phone Number:
Child's School
Child's Grade
Parent's Occupation 
Referral Source:
Describe the present problem: 
Describe your goal for therapy:
Family History:
Is there a family history of speech, language or learning impairments? Please explain:
School History:   
How does your child's teacher describe his/her performance? Does your child struggle with any academics (reading, spelling, math). Please explain:
Interests:
Please share your child's interests or things that motivate your child.
Please select all services that interest you
Is there anything else you want to share?
POLICIES:
Please read & sign the full policy document. 

SUMMARY


1. Prepay for all sessions once month at a time using a tuition-based model to hold your weekly therapy spot on the FIXED schedule.  Invoices sent by the 1st of each month. Payment is due in full by the 25th of each month.

2. Prepay for all sessions at the time of scheduling to hold the therapy spot on the FLEX schedule.  No session will be held without payment.

3. 48-hour cancellation policy. If you cancel with 48-hours’ notice, you may schedule make up sessions. Make up sessions need to be used within 1 month.  If you cancel with less than 48-hours, you can use the time for any family-centered service (online parent consultation, progress note, IEP review, etc.) Please indicate how you want the billable time to be spent before the session time.


4. No refunds.


5. Fee increases by $5 each year on September 1st.

PAYMENT = AGREEMENT TO POLICIES

SIGN AND DATE BELOW TO ACKNOWLEDGE YOU HAVE READ THESE POLICIES

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