Parent 1

Parent 2

Health Condition

Symptoms/Sign to watch for

Actions/Steps to be followed

Health Condition

Symptoms/Sign to watch for

Actions/Steps to be followed

If we are unable to reach you by phone are we to call the ambulance?

I hereby authorize the Pediatric Therapy Clinic, Inc. to furnish the insured’s insurance company all information which may be requested concerning my child.
I hereby assign to the Pediatric Therapy Clinic, Inc. any money for which I am paid for medical expenses related to the services performed at the clinic. I also agree to above emergency information and care plan.

Sex:

Does your child attend preschool or school?

Is child receiving school based therapy

Were there any complications, illnesses and/or accidents during the pregnancy?

Were there any complications with the birth or shortly after?

Other Children in the family:

Does the child have difficulty with any of the following:

At what age did the child

Do you feel the child is well coordinated?

What is the child's dominant hand?

Please check yes or no. If yes, please describe

Family history of learning / neurological disorder

Child takes medication regularly

Child has a hearing problem

Child had hearing test recently

Other signicant medical concerns

Did the child babble and coo as an infant?

What mode(s) of communication does your child primarily use?

Which of the following describs your child's vocabulary best:

Please fill out the following information on the age your child began using language.

Fine Motor Skills:

Body in Space Skills:

Sensory Processing Skills:

Gross Motor Skills:

Gait/Balance: (1+ year old)

Functional School Skills:

Visual Motor/Visual Perceptual:

Activities of Daily Living:

Equipment:

Developmental Milestones:

Financial Policy and Consent

o It is required that all patients be accompanied by a parent or legal guardian at the time of the initial visit.
o We require a 24-HOUR ADVANCED NOTICE FOR ALL CANCELLATIONS.
o Three no-show appointments over a three-month period will result in a discontinuation of services.
o If you arrive late for your scheduled appointment time, you may be required to reschedule so that other patients are not inconvenienced.
o Patients will be responsible for the remainer of their bill not paid by insurance.
o Payments or payment arrangements must be made within 30 days of receipt of the statement.
o An 18% interest may be applied to all statements if payment or payment arrangements are not made within 30 days of receipt of the statement.
o Statements not paid within 90 days are subject to collections.
o All checks returned to us for non-sufficient funds will result in a $35 processing fee. The original check amount plus the processing fee must be paid at your next appointment or within 10 days.
oI understand that Pediatric Therapy Clinic has the right to bill as private pay if the passport referral is not given for the services rendered by the Passport PCP listed with Montana Medicaid.

I understand that I am responsible for:
o Providing (to the extent possible) the treating therapist(s) with information needed in order to receive appropriate care
o Following plans and instructions for care that I have agreed upon with the treating therapist(s)
o Understanding my health problems and participating, to the degree possible, in developing, with the treating therapist(s), mutually agreed upon treatment goals
o Payment of the balance of treatment services not covered by insurance.

I AGREE AND CONSENT TO PARTICIPATE IN THE THERAPY SERVICES OFFERED AND PROVIDED BY THE PEDIATRIC THERAPY CLINIC, INC. I UNDERSTAND THAT I AM CONSENTING AND AGREEING TO THOSE SERVICES.