Today s date (mm/dd/yyyy): Case History: Child s Name: Date of Birth: / / Age: Gender: Male / Female Family Information: Relationship Name Age Living in same Household (Y/N) Mother Preferred method of contact? (email, cell, work, etc) Father Sibling 1 Sibling 2 Sibling 3 Sibling 4 Other: please list any other important family members or caregivers who live or spend significant periods of time with the family (ie., nanny, babysitter, step- parent, grandparent):
Contact Information: Street Address City/State Zip Code Home Phone Cell Phone Work Phone Mom Dad Other Important Caregiver or Family Member 1 Other Important Caregiver or Family Member 2 Email Address Person completing this form: Relationship to child: Birth and Developmental History Born at weeks via (please circle one) C- section vaginal. Were there any complications with the pregnancy or delivery?: Motor Milestones: Rolled over: Sat unsupported: Crawled: Walked: Any current concerns? Y/N If yes, please explain: Speech- language milestones: Cooed: Babbled: Used first word: What was his/her first word? Combined two words (i.e., mommy up, more juice):
Tell Us About Your Child: Please be as complete as possible in your answers. We use the information you give to tailor our programs to the individual needs of your child and family. General Picture: Tell me a little about your child- - just the first things that come to mind. What is his/her language like? Can you have a conversation with your child? Please describe: YES NO Is your child able to tell a coherent story about a past event? For instance, can he/she tell you what happened at school today? What happened at a party? Does your child ever seem to get hung up on small details? YES Please describe: NO
How would you describe your child s behavior to me if I had to pick him/her out in a group of other children the same age? Think about his/her behavior at parties or on the playground. What kinds of things does he/she do when left to his/her own devices? What are your child s favorite activities? Does your child have any particular areas of interest that he/she likes to study/discuss/play? Is your child interested in building friendships? Please describe. Does he/she have a best friend? Y/N If yes, who? Same age? Different age? With whom does he/she interact with best? Adults/kids Same aged peers? Older/younger? Please describe:
Is he/she having any difficulties in school? Are the problems academic, behavioral, social? Please describe: YES NO Is there anything, in terms of strengths, weaknesses, or history that you feel would be helpful for me to know in my time with your child and your family? Current Concerns: Tell Us What s On Your Mind What are your concerns at this moment? What the most concerning difficulties in your daily life? What are the services, schools or programs you are considering? Please let us know how to tailor our services to answer your pressing questions or concerns? (feel free to continue on the back)
Evaluation History Has your child ever been evaluated by an audiologist, speech- language pathologist, clinical psychologist, school psychologist, child psychiatrist, neurologist, or occupational therapist? If so, please indicate below. If reports of these evaluations are available, please attach. Type of evaluation Agency/School District/Clinician Date Is report available? Attached? History of Therapy Services (please begin with 1st services provided, up through current services) Type of therapy (PT/OT/Speech, etc) Inclusive dates Agency/School District Hrs/wk
Educational History Please list the name of each school your child has attended, beginning with current services/enrollment: Inclusive dates Agency/School District Hrs/wk Special therapies provided? (OT/PT/Speech) - present Medical History If your child s medical history includes one of the following, please indicate and note the age when the incident or illness occurred. Please also include any additional pertinent information. Ear problems: Eye/vision problems: Sleep problems: Has your child had a hearing test? Y/ N When?: Where?: (please attach records if evaluation took place within the past year) Does your child wear hearing aides? Y/ N Does your child wear corrective lenses or glasses? Y/ N Is your child legally blind? Y/ N Allergies Type Yes/No Please list Medication Food Environmental respiratory agents Does your child have asthma? Y/ N
Anything Else? Is there anything else that you d like me to know that we have not yet addressed? Thank you so much for your time and effort in completing this intake questionnaire!
Welcome to the Texas Social Communication Connection! We are excited to have the opportunity to work with your family! Please take a moment to review the following guidelines and information. Who are we? : The Texas Social Communication Connection, under the direction of Michelle N. McFarlin, MS, CCC/SLP, is a speech-language pathology private practice strives to be the premiere service provider for in-depth speechlanguage/social communication evaluations, treatment planning, early intervention, and parent education for families of young children with social communication difficulties. Michelle N. McFarlin, MS, CCC-SLP, earned a Bachelors of Arts in Psychology and a Bachelors of Science in Mathematics from Southern Methodist University before receiving a Masters of Science in Communication Disorders from the University of Texas at Dallas-Callier Center for Communication Disorders. She holds a Certificate of Clinical Competence from the American SpeechLanguage and Hearing Association and is a certified by the Texas State Board of Examiners as a clinical SpeechLanguage Pathologist. From graduate studies to present, Mrs. McFarlin has nearly 20 years experience in research and clinical service to young children with communication disorders and their families. How to contact us: You may reach us by phone or text message at (214)457-0588 or by email at michelle.mcfarlin@scc-slp.com Services: We tailor our services to the needs of your child and family. Each family is unique; your service should be too! We offer comprehensive speech-language and social communication evaluations, educational consulting, autism consulting, and small group preschool programs aimed at facilitating social communication, language, and joint play abilities. Visit Length: Evaluations: A typical comprehensive speech-language and social communication evaluation session is approximately 2-hours in length, and includes both standardized and informal measures in order to assess your child s strengths and weaknesses across domains of speech, receptive language, expressive language, social communication, play, and behavior. Prior to initiation of the evaluation, you will receive a quote for the evaluation cost, including full report. Consultations: The length of our planned visit will be mutually agreed upon in advance of your appointment. Visit time is defined as time spent working directly with the child or family; child observation; and consultative time with the family or other professionals, directly or by phone. Drive time for distances of greater than 20 miles from our office will be billed at $75/hour. Prior to initiation of hourly consultation services, the clinician will request written advanced permission from the family to alter the duration of services (spent in observation of the child, coordination of care with other professionals, etc.) at her discretion. If this permission is not granted, the clinician will cease services at the conclusion of the pre-arranged time. Rescheduling or cancellations: It is important that our staff have as much advance notice as possible. We ask that you cancel or reschedule at least 24 hours in advance, except in case of illness or emergency. We will extend you this same courtesy.
Missed and late visits: If an appointment is confirmed and your family is not at the designated location at the designated time, you will be billed for the total fee for the amount of time that had been pre-determined by you and the therapist upon scheduling an appointment. Fees & Billing: The Texas Social Communication Connection does not accept private insurance, Medicaid, CHIPS, or Medicare. We are a fee-for-service agency. 1) If you are scheduled for a fixed-price service, such as a FEEL session or a comprehensive speechlanguage evaluation, you will receive an Invoice for the total amount due for this service at least 24 hours in advance of your scheduled appointment. A note on Comprehensive Speech-Language Evaluations: Cost for a typical speech-language/social communication evaluation, including reporting conference and full report, is $450. However, under some circumstances, more or less time may be required. In such a situation, you shall be notified of the situation prior to any action, and any additional mutually agreed upon time will be billed at $125/hour. 2) If you are scheduled for open-ended hourly consultation services, including educational or autism consulting services, you will receive an Estimated Invoice stating the hourly consultation rate and the estimated amount of time to be spent in these services prior to the consultation date. For consultation services with the family present, the Estimated Invoice will be adjusted upon conclusion of the appointment on the date of service. Payment is due at that time. For more ongoing consultation services in service to a mutually agreed upon goal, including professional interviews, child observation at school or therapy, coordination of care with other professionals, etc., Invoices will be sent electronically at the conclusion of the project, or at a time interval (daily, weekly, monthly) requested by the family and agreed upon by the director. Payment: We accept payment by check, written to The Texas Social Communication Connection. A returned check fee of $25 may be charged for insufficient funds. We also accept MasterCard and Visa. Credit card payment and bank transfers may be made online through QuickBooks. For fixed-price services, payment should be received prior to the start of each appointment. For consultation services at an educational or therapy facility when the parent is not present, or for phone consultations, you will receive an electronic invoice. Payment is due within one week of receipt of Electronic Invoice. (If payment is not received within one week of the Electronic Invoice for a billed service, a late fee of $50 will be applied. If payment is not received within 2 weeks of the Final Invoice, a late fee of $100 will be applied. If payment is not received within 3 weeks of the Final Invoice, The Texas Social Communication Connection will begin taking legal action.) I understand and agree to these Policies and Procedures. Parent Signature: Date:
Notice of Privacy Practices THIS NOTICE IS EFFECTIVE APRIL 1, 2014. IT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT US AT (214)457-0588. This Notice of Privacy Practices describes how The Texas Social Communication Connection PLLC may use and disclose your protected health information. It also describes your rights to access and control your protected health information. Protected health information is information about you, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. This notice refers to practices followed by our medical and administrative staff, while you are a patient of The Texas Social Communication Connection PLLC. This notice refers to services provided at our office, the patient s home or other natural environment. If we have been contracted to provide services on behalf of another entity or in another facility not owned or operated by The Texas Social Communication Connection PLLC, other policies may apply. Uses and Disclosures of Protected Health Information Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to physicians or case managers involved in your care, etc. to ensure that the healthcare provider has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining payment for therapy may require that your relevant protected health information be disclosed to the health plan. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support business activities. These activities include, but are not limited to, quality assessment, employee review and training. We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. We may use your health information to communicate with you about treatment related benefits that could be of interest to you, to obtain payment for services or to conduct our business operations. However, we do not receive financial remuneration from a third party in exchange for making these communications. We may contact you by phone to schedule appointments or to follow up on our care. It is our policy never to leave vital health care information on voice mail. With your permission, we may share your health information with those you tell us will be helping your child or family member with her/her therapy program. We may use or disclose your protected health information in the following situations without your authorization: as permitted by the HIPAA Privacy Rule, as required by law, emergencies, abuse or neglect, auditing purposes, research, criminal activity, workers compensation, and other required uses and disclosures. The Texas Social Communication Connection PLLC may use or disclose your health information if we have removed information that might identify you. The Texas Social Communication Connection PLLC does NOT sell or disclose your protected health information for external marketing or fundraising. Any uses and disclosures other than those permitted by the HIPAA Privacy Rule will be made only with your written authorization. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. You may request that we transfer your records to another person or organization by completing a written authorization form.
Rights of the Individual You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice at anytime. When changes are made, a new Notice of Privacy Practices will be mailed to you. You may also request a current copy of our notice at any time. You have the right to inspect and copy your protected health information (fees may apply), whether in paper or electronic format. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. The Texas Social Communication Connection PLLC is not required to agree to your requested restriction except if you request that The Texas Social Communication Connection PLLC not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket. You have the right to request an amendment to your protected health information If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to receive an accounting of certain disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request. You have the right to receive notice of a breach if your unsecured protected health information has been breached. You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control privacy of health information of minors unless the minors are permitted by law to act on their own behalf. All requests must be made in writing. The Texas Social Communication Connection PLLC will consider all written requests on a case by case basis, but the practice is not legally required to accept them. Concerns and Complaints If you are concerned that your privacy rights may have been violated, if you disagree with any decisions we have made regarding use or disclosure of your personal health information or to file a complaint, please contact the person listed below. No one will retaliate or take action against you for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services. Privacy and Security Officer: Michelle McFarlin; privacy and security officer, The Texas Social Communication Connection, PLLC Address: 7007 Meadow Lake Ave., Dallas, Texas 75214 Email: michelle.mcfarlin@scc-slp.com
Patient Consent and Authorization Form 1. I hereby consent to and acknowledge receipt of The Texas Social Communication Connection PLLC s Notice of Patient Privacy Practices. I consent that my protected health information be used to provide and coordinate treatment, to obtain payment, and for business operations. I understand that The Texas Social Communication Connection PLLC s Notice of Patient Privacy Practices explains my rights to privacy regarding my protected health information and provides specific information and a complete description of how my health information may be used and disclosed. 2. I authorize The Texas Social Communication Connection PLLC to render appropriate therapy services to the below named patient. I understand that care will be provided by an appropriately trained health care professional. I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying the The Texas Social Communication Connection PLLC office in writing. In addition, The Texas Social Communication Connection PLLC may terminate services by notifying me of termination. 3. I consent and agree that The Texas Social Communication Connection PLLC and its staff may contact me by: email at: leave voice messages at the following phone number(s): send me text messages at the following phone number(s): I understand that these messages can include protected health information, such as patient name, appointment information, billing information, information that identifies the practice as a speech therapy practice, and any pertinent clinical information. I understand that text messages and emails are not secure forms of communication, and that by consenting to these communication types, I am waiving my rights to secure electronic communications. I do NOT want to receive messages, text messages or emails that contain protected health information. 4. I understand that for the purpose of continuing and coordinating my plan of treatment The Texas Social Communication Connection PLLC may be asked to release copies of my medical records, or such portions thereof as may be relevant to speech language pathology evaluation or treatment services, or reports or summaries thereof, to other health care providers, facilities (related school or daycare staff, case managers, school system, etc.) and appropriately related professionals involved in my care. My signature below indicates that I hereby authorize the release and disclosure of my protected health information to the following people on an as-needed basis as determined by The Texas Social Communication Connection PLLC staff (choose all that apply): Release to other Entity or Individual: Individual Organization/Relationship Address Phone Number
Individual Organization/Relationship Address Phone Number This authorization will EXPIRE in one year, or upon my discharge from patient services or upon my written request to deny future releases. Any individuals or entities that I do NOT want my health information released to are listed specifically below: Patient Name (print): Patient DOB (mm/dd/yyyy): Parent/Authorized Representative SIGNATURE Release of liability: I certify that my child is in good physical condition and I agree, individually and on behalf of my child, to hold The Texas Social Communication Connection PLLC, Highland Park Presbyterian Day School, Highland Park Presbyterian Church, and Lakewood United Methodist Church harmless from all liability and to fully indemnify any harm or damage, including any harm or damage caused in any part by the negligence of The Texas Social Communication Connection PLLC. This application has my consent and approval. Parent signature: Consent to Treat I have read and fully understand the content of this consent and authorization release and hereby agree to and authorize the foregoing provisions. As used in this document, the terms I, me and my refer to and include, in addition to the undersigned, the patient named above and other for whom he undersigned is responsible or for whom the undersigned has assumed responsibility engaging in Texas Social Communication Connection to provide services to the patient. This consent and authorization is valid until revoked by me in writing. Parent signature: Date: