Therapy Intake Form

Skip to content

Homepage
About
Insurance
Services
Careers
Contact
FAQ
Testimonials
Parents
Blog
Playspace
Intake Form

Youtube Facebook Instagram

1Patient Information

2 Insurance Information

3Financial Responsibilities

4 Insurance Coverage

5Kidology No-Show/Late Policy

6 Legal Guardian Consent Form

7Referral Source Questionnaire

Patient Information
Patient's Name*
First Last
Date of Birthday
MM slash DD slash YYYY
Age
Gender
- Male
- Female
PARENT/GUARDIAN INFORMATION:
Parent #1 Name:
Date of Birthday
MM slash DD slash YYYY
Address
Street Address
Phone #1
Phone #2
Email*
Parent #2 Name:
Date of Birthday
MM slash DD slash YYYY
Address
Street Address
Phone #1
Phone #2
Email*
What services are you interested in?
- Speech therapy
- Occupational Therapy
- Physical Therapy
- ABA Behavior therapy
Medical Conditions
Does your child have any diagnosed medical conditions?*
- Yes
- No
Please express your concerns pertaining to the child below:*
We strive to provide the best care for every child at our facility. To ensure we meet your child's needs effectively, please provide information about any diagnosed medical conditions.

Please fill out the form below and attach a copy of any relevant diagnosis documents. This information will be kept confidential and will only be shared with staff directly involved in your child's care.
Hidden
We strive to provide the best care for every child at our facility. To ensure we meet your child's needs effectively, please provide information about any diagnosed medical conditions. Please fill out the form below and attach a copy of any relevant diagnosis documents. This information will be kept confidential and will only be shared with staff directly involved in your child's care.

We strive to provide the best care for every child at our facility. To ensure we meet your child's needs effectively, please provide information about any diagnosed medical conditions.

Please fill out the form below and attach a copy of any relevant diagnosis documents. This information will be kept confidential and will only be shared with staff directly involved in your child's care.
Diagnosed Medical Condition(s):*
Upload Diagnosis Document(s):*
Drop files here or

Accepted file types: doc, docx, pdf, png, webp, Max. file size: 50 MB.
Child's Full Name*
First Name Last Name
Child's DOB*
MM slash DD slash YYYY
Disclaimer: By submitting this form, you consent to the collection and use of this information for the purpose of providing appropriate care for your child. For more information on how we handle your data, please refer to our Privacy Policy. Thank you for helping us ensure the best possible care for your child!
Are you currently receiving Services/Therapy anywhere else*
- Yes
- No
Place of Services/Therapy*

Insurance Information
Primary Insurance-Policy Holder*
Employer
Relationship
Date of Birthday
MM slash DD slash YYYY
Policy Holder Address
Policy Holder Phone
Insurance Provider
Insurance ID
Group
Secondary Insurance-Policy Holder*
Employer
Relationship
Date of Birthday
MM slash DD slash YYYY
Policy Holder Address
Policy Holder Phone
Insurance Provider
Insurance ID
Group
Other Insurance
Employer
Relationship
Date of Birthday
MM slash DD slash YYYY
Policy Holder Address
Policy Holder Phone
Insurance Provider
Insurance ID
Group
Primary Physician
Physician Phone
Physician Fax
Primary Physician Practice Name
Location
Parent/Guardian Signature*
Date
MM slash DD slash YYYY

Financial Responsibilities
Dear Parent,

Positive verification of your coverage cannot always be made at the time of service. You will receive services with the understanding that in the event your coverage is not effective, you will be billed and held financially responsible for these services rendered.
Patient’s Name
Date of Birthday
MM slash DD slash YYYY
Parent’s phone number
Name
Emergency Contact Name
Phone
I have read the above and understand my possible financial responsibilities of services rendered and hereby affix my signature as an acknowledgement of this understanding.
Parent/Guardian Signature*
Date
MM slash DD slash YYYY

Insurance Coverage
AS A MEDICAL PROVIDER, OUR RELATIONSHIP IS WITH YOU AND NOT YOUR INSURANCE COMPANY. IT IS YOUR RESPONSIBILITY TO KNOW YOUR POLICY. WE CAN ONLY TELL YOU OUR CHARGE, AMOUNT PAID AND AMOUNT OWED.
INSURANCE COVERAGE
- It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions, and limitations as well as pre-authorization requirements. This information is furnished by the insurance carrier.
- If your coverage is not in effect at the time for your visit, the financial responsibility forpayment is yours.
- If you have any changes in your insurance coverage, you must notify us.
DEDUCTIBLES, CO-PAYMENTS, CO-INSURANCE & NON-COVERED SERVICES
- Deductibles are the patient’sresponsibility. The deductible is determined by thecontract you have with your insurance carrier. We do not know how much eachperson’s deductible is and how much has been met at the time of your visit.
- Co-payments and co-insurances are the patient’sresponsibility.
- All patients are responsibility for “non-covered” services if denied by their insurancecarrier.
REFERRALS
- It is your responsibility to obtain referralsif required to do so by your plan.
INSURANCE REQUESTS
- You are responsible for responding to any requests from the insurance company for further information. Not doing so will result in a claim denial and you will be responsiblefor payment.
INSURANCE PAYMENTS SENT TO YOU
- If insurance payments are sent to you, you are responsible for forwarding them to ouroffice with a copy of explanation of Benefits (EOB) received.
Parent/Guardian Signature*
Date
MM slash DD slash YYYY

KIDOLOGY NO-SHOW/ LATE POLICY
Welcome to KIDOLOGY Therapy services. We ask that you please take the time to review the following policy regarding no show, late arrival, and cancellation of teletherapy/home/office/daycare appointments.

We understand that scheduling conflicts, emergencies, and illnesses can occur from time to time. However, we request that you give 24-hour notice if you are not going to be able to attend your scheduled appointment.

If you need to cancel your child’s session, you need to contact the office within 24 hours. 215-330-4116 or text 267-560-7564

Failure to give 24-hour notice will result in a no show/cancellation fee of $40.

We thank you for respecting our therapists’ time and commitment to providing excellent services to you and your family.

Should you have to cancel due to illness or death in the family, please provide a note to be exempt from the fee- failure to provide a note, fee WILL NOT be exempt.
Read and understand this policy. You may be provided with a copy upon request.
Parent/Guardian Signature*
Date
MM slash DD slash YYYY

Legal GUARDIAN CONSENT FORM
My Child has been referred to Kidology Inc for services.
Client Name
The current legal guardians of
Client Name
Legal Guardian Name
Legal Guardian Name
Sole Custody?
- Yes
- No
If yes, we will need legal documentation before providing services.
Joint Custody?
- Yes
- No
We will need both parents’ consent and signatures before providing services.
I/we give Kidology Inc permission to treat my child.
** In the event of no formal custody arrangements, or joint legal custody, we must have written consent of both parents.
Signatures required by both parties if there is joint custody:
Legal Guardian Signature*
Date
MM slash DD slash YYYY
Legal Guardian Signature*
Date
MM slash DD slash YYYY

Referral Source Questionnaire
Date
MM slash DD slash YYYY
Patient Name
Please take a moment to let us know how you were referred to our practice. (Please select only one referral source)
Referral Source
Name of Practice or Doctor
Name of Provider
Other Referral Source
Thank you for taking a moment to complete this questionnaire.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

215-330-4116
Luba@kidologyinc.com

928 Jaymor Rd. Unit C-150
Southampton, PA 18966
2810 Southampton Rd,
Philadelphia, PA 19154
230 174th Street, bldg
300 unit 419, Sunny Isles, FL 33160

Keep in touch

Therapy intake form

Patient Information

PARENT/GUARDIAN INFORMATION:

Medical Conditions

Insurance Information

Other Insurance

Financial Responsibilities

Dear Parent,

Positive verification of your coverage cannot always be made at the time of service. You will receive services with the understanding that in the event your coverage is not effective, you will be billed and held financially responsible for these services rendered.

Insurance Coverage

INSURANCE COVERAGE

DEDUCTIBLES, CO-PAYMENTS, CO-INSURANCE & NON-COVERED SERVICES

REFERRALS

INSURANCE REQUESTS

INSURANCE PAYMENTS SENT TO YOU

KIDOLOGY NO-SHOW/ LATE POLICY

Legal GUARDIAN CONSENT FORM

Signatures required by both parties if there is joint custody:

Referral Source Questionnaire