Client Information

1
Client Information
Name____________________________________
Date of Birth: ______________________________
Parents’ Names: ____________________________________________________________________________
Address: __________________________________________City:___________________Zip:______________
Phone Number: ___________________________ Cell Phone Number: _______________________________
Email: _________________________________________ Communication preference:
home
cell
email
Diagnosis (if known): _______________________________________________________________________
Primary Physician: ____________________________
Phone Number: ____________________________
Physician’s Address: ________________________________City:____________________Zip:_____________
Referring Physician (if different): ________________________
Phone Number: ______________________
Please list other specialists working with your child:
Name
Specialty
Phone Number
How did you hear about Building Bridges Therapy? _______________________________________________
Insurance Information
Primary Insurance Company:___________________________Person Insured:__________________________
Insurance Address: __________________________________________________________________________
Insurance Phone #: _____________________ Policy #: _______________________ Group #: _____________
Secondary Insurance Company:___________________________Person Insured:________________________
Insurance Address: __________________________________________________________________________
Insurance Phone #: _____________________ Policy #: _______________________ Group #: _____________
Medicaid #: _______________________________________Effective Date:____________________________
Family History
Mother’s Name: ___________________________________ Date of Birth: ____________________________
Occupation/Employer: _______________________________________________________________________
Father’s Name: ___________________________________ Date of Birth: ____________________________
Occupation/Employer: _______________________________________________________________________
Marital Status: Single
Married
Divorced
Separated
Widowed
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
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Brother(s), Sister(s), or others living with the child:
Name
Age
Why are you seeking the services of Building Bridges Therapy:
__________________________________________________________________________________________
__________________________________________________________________________________________
Has your child previously received therapy services?
yes
no
If “yes”, where and when: ____________________________________________________________________
Birth History and Development
Is your child adopted?
yes
no
If so, at what age? __________________________
Were there any complications during pregnancy (illness, injury, infection, etc)? If so, please describe:
__________________________________________________________________________________________
Were any medications taken during pregnancy or delivery? __________________________________________
Location of Birth: _________________________________ Birth Weight: ______________________________
Was pregnancy full-term? _________________Please describe labor (normal, long, induced, etc): __________
Describe delivery (normal, caesarean, breech, forceps used, etc): _____________________________________
Please list any complications at birth:
__________________________________________________________________________________________
Describe any congenital defect: ________________________________________________________________
Does your child have any other medical issues:
__________________________________________________________________________________________
Please list any hospitalizations and/or medical procedures you child has had:
__________________________________________________________________________________________
Please list current medications:
Name
Dosage
Frequency
Reason for Medication
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
3
Please list any known allergies or dietary restrictions: _____________________________________________
Has your child ever had a psychological, developmental, neurological, psychiatric, EEG, or MRI evaluation? If
so, why and what were the results?
__________________________________________________________________________________________
Speech and Language Developmental History
At what age did your child do the following:
Say single words: ________Put 2-3 word together: ________What were his/her first words? _______________
Does your child understand or speak another language other than English? _____________________________
Motor Development
At what age did your child do the following:
roll over: __________ crawl: __________
sit alone: __________ walk: __________
drink from cup: ________chew solid food: _________eat with utensils: ________tie shoe laces: __________
Was the crawling phase prolonged, brief, or almost eliminated? _____________________________________
Please check if your child is able to do the following:
Activity
Yes
No
Hop on one foot
Skip with both feet
Ride a bicycle
Jump Rope
Cut with scissors
Color inside the lines
Have consistent hand dominance
Educational Information
Is your child currently in school? yes no
Name of School: ___________________________
What days does your child attend school? ____________________________________________
Does your child receive any services through school? yes no
If yes, what services?
__________________________________________________________________________________________
Does your child have a current Individual Education Plan? yes no If yes, please provide a copy.
Social/Emotional History
What are your child’s favorite toys/activities?
__________________________________________________________________________________________
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
4
How does your child play with other children?
__________________________________________________________________________________________
Is your child currently enrolled in any community activities?
__________________________________________________________________________________________
Is there anything else we should know about your child or family?
__________________________________________________________________________________________
Preferred day and time for therapy: _________________________________________________
Signed ___________________________________________________________Date _______________
Parent/ Legal Guardian
Relationship
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
5
CHILD’S NAME:_______________________________ DATE OF BIRTH:__________________
FINANCIAL AND INSURANCE POLICY
Updated 4/1/2012
Insurance information will be needed before services begin to verify benefits. A copy of your insurance card(s)
and driver’s license is required. Benefits will be verified upon receipt of your insurance information and you
will be made aware of any estimated out-of-pocket expenses. Information gained from insurance companies
during verification of benefits, however, is not guaranteed. Please notify Building Bridges Therapy of any
changes in insurance or Medicaid coverage. It is imperative that families are aware of their insurance coverage
and their potential responsibilities. We will strive to keep open communication in regards to insurance and
payment.
Building Bridges Therapy, Inc charges the usual and customary rate for one hour of therapy services. If you do
not have insurance coverage for therapy services a payment plan can be arranged. Payment for private pay
sessions is due at the time of service. Building Bridges Therapy is an In-Network provider for Aetna, BCBS,
United Healthcare, Tricare, and Medicaid. All other insurances will be billed as out-of-network. Unless your
child has Medicaid, families are responsible for all co-pays, co-insurances, and deductible expenses.
________parent initials
For qualified children under the age of three, the Babies Can’t Wait program will be billed only when all other
sources of payment are exhausted. There may be a family cost participation involved with the BCW program,
which will be collected at the time of service or billed to the family. I understand that I am responsible for
payment of any services in excess of your Babies Can’t Wait IFSP.
________parent initials
Katie Beckett Medicaid, SSI Medicaid, Amerigroup, and Wellcare are accepted. We are not contracted with
Peachstate. Insurance will always be billed first and Medicaid will be billed secondary unless it is the primary
source of payment. Prior approvals are required for therapy services over 8 units per month. Therapists will
submit for prior approvals based on need. Services will be administered after approval has been obtained.
________parent initials
Building Bridges Therapy, Inc will bill insurance the usual and customary rate for ABA Therapy. I understand
if my insurance does not cover ABA Therapy I will be responsible for the private pay rate per one hour of
ABA/ therapeutic activity: $60 with BCBA, $40 with behavioral therapist, $35 four hours or more weekly with
behavioral therapist. Payment for private pay sessions is due at the time of service. The fee for an initial ABA
appointment is $160.00. This appointment will allow initial assessment to take place, as well as development of
goals and documentation binder. This assessment is an out-of-pocket expense and payment is expected at the
time of service.
________parent initials
If payment has not been received within 60 days from the date of service, families will be responsible for the
balance. If a family does not pay a bill within 30 days of receipt, there will be a 10% late fee added.
________parent initials
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
6
As in all health-care situations, the client-family is always responsible for payment when all other sources have
been exhausted. Therapy services may be put on hold or terminated if there is a problem regarding payment.
There is a $25 service fee for all returned checks.
Please do not hesitate to contact us regarding questions of billing/payments. We are willing to work with each
client to insure a balance between providing therapy services and addressing business issues or concerns.
I have read and understand the above billing policy.
Signed ___________________________________________________________Date _______________
Parent/ Legal Guardian
Relationship
CONSENT FOR PAYMENT
I authorize Building Bridges Therapy, Inc. to bill my insurance company for direct reimbursement of therapy
services rendered to my child. I assign benefits for filed claims to be paid to Building Bridges Therapy, Inc and
will turn over any payments sent directly to me by my insurance provider that were intended to cover the
therapy services provided by Building Bridges Therapy. I understand that I am responsible for payment of any
services not paid by insurance.
Signed _________________________________________________________ Date ________________
Parent/ Legal Guardian
Relationship
ATTENDANCE POLICY
Building Bridges Therapy, Inc’s policy states that we require a 24 hour notice for cancellations. After a onetime occurrence, a $25 fee may be charged for each missed therapy appointment. We know that sickness
occurs; therefore, if you think that your child is sick the night before, please call us and give us notice so we can
plan accordingly. If your child is fine the next day, we will make every effort to reschedule.
In the event of a cancellation, please make an effort on your part to reschedule as we want your child to benefit
from his/her therapy.
Additionally, if your child misses 3 consecutive weeks of therapy, we will make every attempt to hold that slot,
but cannot guarantee this with an extended absence.
We at Building Bridges Therapy strive to meet the scheduling needs of every family. If your therapy time does
not work for you, please let us know.
The Board of Health considers the following signs to indicate communicable disease/illness:
Vomiting
Fever over 100 degrees
Diarrhea
Sore throat
Rash /Swelling
Red, or running eyes
Please be sure your child is symptom free for 24 hours before resuming therapy.
Parent/Guardian Signature: ______________________________________
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
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CONSENT FOR TREATMENT
I, ______________________ (caregiver’s name), knowing that _______________________ (child’s name) has
a diagnosis requiring physical, speech, occupational, and/or ABA therapy treatment, voluntarily consent to such
care for the aforementioned child by the therapist doing business for Building Bridges Therapy, Inc. as may be
beneficial in the professional judgment of this child’s therapist. I consent to care and treatment that falls within
the scope of practice as defined by the State of Georgia for each discipline. I understand that treatment will
involve physical participation on the part of the patient which may involve risks of injury. You are responsible
for making your therapist aware of any changes in your child’s physical or mental status. I acknowledge that no
guarantee has been made to me as the result of evaluation and/or treatment. Building Bridges Therapy is a
teaching facility and supervised students or volunteers may participate in your child’s treatment session.
Signed ______________________________________________
Parent/Guardian
Relationship
Date ___________
In my absence, I consent that_______________________ (child’s name) may receive therapy under the care of:
_____________________________________________________________________________.
(List all caregivers, teachers, daycare providers, etc. that may be present during therapy in your absence.)
Signed _______________________________________________
Parent/Guardian
Relationship
Date _________
CONSENT TO EXCHANGE INFORMATION
I authorize Building Bridges Therapy to release or communicate necessary and pertinent information to
physicians, case managers, and insurance companies for my child _____________________.
Approved information may be given to, received from, and discussed with the following people directly related
to my child’s care. Approved information includes written documentation and/or verbal discussion.
Other Therapists: ___________________________________________________________________________
School Name: _____________________________________________________________________________
Please list any others:________________________________________________________________________
Signed _______________________________________ Printed Name ____________________Date ________
Parent/Guardian
NOTICE OF PRIVACY POLICY
I have read, understand, and agree to the Building Bridges Therapy Notice of Privacy Policy. I understand I
may request a copy of this policy at any time. I consent to receive communication regarding my child’s therapy
via (circle all that apply) phone messages at home or cell phone, email address: __________________________
Signed _______________________________________ Printed Name ____________________Date ________
Parent/Guardian
Building Bridges Therapy
2450 Atlanta Hwy Ste 903
Cumming, GA 30040
770-886-6204
fax 678-261-6421
www.buildingbridgestherapy.com
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