Turner Speech Intake Form
Welcome to Turner Speech & Language Services, LLC!!
Thank you for choosing Turner Speech to assist you with your communication needs.
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Email *
Today's date *
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Patient Name/ Date of Birth *
Parent/Guardian Name *
Home Address *
Phone number *
Place of employment/Contact number *
Language(s) spoken in the home *
Required
Physician/Pediatrician *
Contact information for physician/pediatrician *
Most recent visit: *
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Are immunizations up-to-date? *
Please describe current concerns for speech/language: *
Have you received a previous evaluation at another facility to address speech/language concerns? Date of completion? Outcome? *
Please list the child care facility or school that your child attends.  *
What grade are they in? Who is their teacher? How does the teacher/instructor provide support regarding current speech/language concerns? *
Has your child ever repeated a grade? *
Does your child have a current Individualized Education Plan (IEP) or a 504 plan? *
Describe all services received (speech therapy, physical therapy, occupational therapy, behavioral therapy) at school? If applicable, please include therapy minutes received per week. *
How is your child impacted by the current speech/language concerns within the school setting? What about in other social environments? *
What are your child's strengths? What is he/she good at? *
What are your child's weaknesses? What are some areas in which they could improve? *
Have there been any significant environmental changes, family events, and/or medical concerns that have occurred in the last 6 to 12 months? *
History of hearing or vision issues? Recurring ear infections? Have you had a recent hearing or vision screening? If so, what were those results? *
History of swallowing or feeding disorders? Have you had a recent video fluoroscopic swallowing test? If so, what were those results? *
Please list all allergies? *
Current medication? *
Have you observed noticeable habits or repetitive like behaviors? Do you have concerns for Autism? *
Is there a family history of specific diagnoses or issues? *
Take this space to tell us anything else that you think is important. *
What is your preferred method of contact? *
Required
Consent Form: This must be completed before services can be initiated. If the patient is under the age of 18 years old, acknowledgement must be received from a parent and/or guardian. Do you acknowledge this consent form? *
I hereby attest that I have voluntarily applied for and initiated assessment by Turner Speech & Language Services, LLC. Following an assessment, if treatment is deemed necessary based on the clinical judgment of therapists employed by Turner Speech & Language Services, LLC, my answer below indicates my consent to assessment and treatment. I understand that I may terminate this consent and all services at any time with a verbal and/or written seven day notice. *
Please enter your name below to indicate agreement. *
Enter the name, date of birth, and contact number of the individual responsible for payment: *
POLICIES: We reserve the right to participate with insurance companies of our choosing. We are constantly assessing the needs of our clients and considering expansion of our credentialing with insurance providers. Turner Speech & Language Services, LLC is a private service practitioner. At this time, we do not bill insurance directly. Therefore, we are considered an OUT-OF-NETWORK provider. It is your responsibility to contact your insurance provider to inquire about your coverage and procedures for reimbursement of out-of-network expenses. We are happy to provide you with a copy of your paid invoice to assist you in seeking reimbursement. Please be aware that if your insurance carrier does not reimburse you for services rendered, it is still your responsibility to pay in full for all services provided. Do you agree with this policy? *
PAYMENT POLICY: Timely payment is due for all services rendered. Accounts more than 10 days past due will be assessed a $25 late fee plus a 10% interest charge. Do you agree with this policy? *Please note that we do offer reasonable payment packages to assist our families. *
APPOINTMENT POLICY: If you must cancel a scheduled appointment, please call immediately. Except under emergency situations, all appointments cancelled with less than 24 hours notice will be subject to a $25 service fee. If you will be late for your appointment, please notify us asap. We understand that situations may arise, but please be respectful of our time. Do you agree with this policy? *
FEES POLICY: We will always inform you of the charges for services prior to providing any type of clinical service. Under the No Surprises Act, you will receive an oral and/or written summary that contains a "Good Faith Estimate" of expected charges. Fees apply to various types of services including direct client contact, phone consultations, telehealth services, travel, and consultations with other professionals. Do you agree with this policy? *
PRIVACY POLICY: I understand how medical records and personal information contained in those medical records will be used for assessment and treatment purposes only. I understand that said information will not be disclosed under applicable Federal and State Law without my written consent. I fully understand and accept the terms of this consent. I understand that I may revoke this consent in writing at any time. I understand that Turner Speech & Language Services, LLC reserves the right to modify its policies and that an updated copy of any revised policy will be available to me within 30 days of the date of changes. Do you agree with this policy? *
Enter your name and today's date in the section below to indicate complete understanding and full agreement with all applicable policies and procedures. *
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