Park Cities Speech – child-case-history

Child Case History

Child's Name

DOB

Grade Level

Parent's Names

Home Ph.

Work Ph.

Mother's cell

Driver's License #

Father's cell

Driver's License #

Address

City State Zip

Parent(s) email address(es)

Name of School

Teacher

Pediatrician

Dentist (if applicable)

Insurance Provider

Address

Phone

Medical History/Allergies

Describe Concerns

Describe Development Milestones (age talk, walk, etc.)

Academic Performance

Insurance Carrier

Policy Holder's Name

Date of Birth

Group #

ID #

Your monthly statement will list a treatment and diagnosis code necessary to file insurance. If you would like additional assistance in filing insurance, please see the office manager.

Do you object to the release of relevant information concerning your child's progress (to teachers, pediatricians or insurance companies)?

Yes No

How were you referred to us?

Name

Date

Step 1 of 3

Child’s Name *

DOB *

Grade Level *

Parent’s Names *

Home Ph. *

Work Ph. *

Mother’s cell *

Driver's License #

Father’s cell *

Driver's License #

Address *

City State *

Zip *

Parent(s) email addres(es)

Name of School *

Teacher *

Pediatrician

Dentist (if applicable)

Insurance Provider

Address

Phone

Medical History/Allergies

Describe Concerns

to Driver's Layout

Describe Development Milestones (age talk, walk, etc..)

Academic Performance

Do you object to the release of relevant information concerning your child’s progress (to teacher’s, pediatricians, or insurance companies)?

How were you referred to us?

Print Name

Signature

Clear Signature

Date / Time

If you wish to be billed monthly, we are happy to do so with the provision of this additional information. Since monthly billing is essentially establishing credit, we require the following information if you choose not to submit payment at the time of service. We understand that much of this information is personal. We certainly respect your right to keep this information private, but ask that you pay at the time of service.

Child’s Name *

DOB

Mother’s Driver's License #

Father’s Driver's License #

Mother's Address *

City State *

Zip

Driver's License #

Father's Address *

City State *

Zip

Driver's License #

Are parents married or divorced?

Married
Divorce

Are parents living in the same household?

At Park Cities Speech, Language & Learning Center, it is our priority to care for the well-being of the children we service. In no circumstances are we the mediator between parents. We will continue to encourage you to keep open lines of communication with regard to the speech language program that we are all partnered to provide to your child. The following explains the responsibility of the parents and what the staff &providers at Park Cities Speech, Language & Learning Center will be able to do for you. Custodial Agreements: Our office requires a copy of the legal custodial agreement which will be filed in the child(ren)’s chart(s). Unless otherwise stated in the Custodial Agreement, both biological parents have the right to schedule or cancel appointments. Personal and Insurance information: The biological parents or legal custodian(s) are required to inform our office immediately of any changes in address, contact numbers, court order, or insurance information. Payment Unless formal monthly billing has been established with our office, it is the responsibility of the person who brings the child to the appointment to make payment for that visit. If the parent who accompanies the child does not pay at the time of visit, a billing statement will be generated (including the billing fee) and sent to both parent addresses. By signing this agreement, both parents acknowledge understanding that unpaid balances will be the responsibility of both parents (if there is joint custody) . If all billing attempts are exhausted and payment has not been received, both parents will be turned over for collection. The parent who has primary custody of the child(ren) has the ability to sign a release form for record transfer. In the event that there is joint custody, both parents will need to sign a release form for the record transfer.

PLEASE SIGN BELOW:

I understand and agree to the above policy.

Clear Signature

Signature Relationship to patient Date

I understand and agree to the above policy.

Clear Signature

Signature Relationship to patient Date

Date

At Park Cities Speech, Language & Learning Center, it is our priority to care for the well-being of the children we service. In no circumstances are we the mediator between parents. We will continue to encourage you to keep your lines of communication open between each other as well as your child(ren) with regard to the speech language program that we are all partnered to provide to your child. The following explains the responsibility of the parents and what the staff and providers at Park Cities Speech, Language & Learning Center will be able to do for you. Custodial Agreements Our office requires a copy of the legal custodial agreement which will be filed in the child(ren)’s chart(s). Unless otherwise stated in the Custodial Agreement, both biological parents have the right to schedule or cancel appointments. Personal and Insurance Information The biological parents or legal custodian(s) are required to inform our office immediately of any changes in address, contact numbers, court order, or insurance information. Payment Unless formal monthly billing has been established with our office, it is the responsibility of the person who brings the child to the appointment to make payment for that visit. If the parent who accompanies the child does not pay at the time of visit, a billing statement will be generated (including the billing fee) and sent to both parent addresses. By signing this agreement, both parents acknowledge understanding that unpaid balances will be the responsibility of both parents (if there is joint custody). If all billing attempts are exhausted and payment has not been received, both parents will be turned over for collection. Record Transfer The parent who has primary custody of the child(ren) has the ability to sign a release form for record transfer. In the event that there is joint custody, both parents will need to sign a release form for the record transfer.

PLEASE SIGN BELOW:

I understand and agree to the above policy.

Clear Signature

Signature Relationship to patient Date

I understand and agree to the above policy.

Clear Signature

Signature Relationship to patient Date

Date

Childs Name