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Kidology Phone 215-330-4116 ST/OT/PT Intake Form ABA Therapy Form Shop

Therapy intake form

Home Therapy Intake Form

    Step 1 of 6

    Patient Information

    Tell us about your child and how to reach you.

    Parent / guardian

    How can we help?

    Choose one or more. The concern options below follow your choice.

    Pick the concerns that apply. The options follow the services you selected above.

    Speech Therapy
    Occupational Therapy
    Physical Therapy
    Step 2 of 6

    Insurance Information

    So we can check your coverage before the first visit.

    Primary care physician

    Step 3 of 6

    Financial Responsibilities

    Please read and sign to confirm you understand.

    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.

    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.

    Step 4 of 6

    Insurance Coverage

    What your policy covers is between you and your insurer.

    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 of your visit, the financial responsibility for payment 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’s responsibility. The deductible is determined by the contract you have with your insurance carrier. We do not know how much each person’s deductible is and how much has been met at the time of your visit.
    • Co-payments and co-insurances are the patient’s responsibility.
    • All patients are responsible for “non-covered” services if denied by their insurance carrier.

    Referrals

    • It is your responsibility to obtain referrals if 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 responsible for payment.

    Insurance payments sent to you

    • If insurance payments are sent to you, you are responsible for forwarding them to our office with a copy of the explanation of benefits (EOB) received.
    Step 5 of 6

    No-Show / Late Policy

    How cancellations work, so there are no surprises.

    Welcome to Kidology therapy services. Please take a moment to review the following policy regarding no-shows, late arrival, and cancellation of teletherapy, home, office and daycare appointments.

    We understand that scheduling conflicts, emergencies and illnesses happen. We ask that you give 24-hour notice if you are not going to be able to attend your scheduled appointment.

    To cancel your child’s session, contact the office within 24 hours on 215-330-4116, or text 571-628-0983. Failure to give 24-hour notice results in a no-show/cancellation fee of $50.

    Should you have to cancel due to illness or a death in the family, please provide a note to be exempt from the fee. Without a note the fee will not be exempt.

    We thank you for respecting our therapists’ time and their commitment to providing excellent services to you and your family. You may be provided with a copy of this policy on request.

    Step 6 of 6

    Legal Guardian Consent

    The last one — then you are done.

    If yes, we will need legal documentation before providing services.

    If yes, we 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

    Thank you for taking a moment to complete this form. We will be in touch shortly.