Case History Form - Miracle Farm Speech Therapy

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Miracle Farm Speech Therapy

Case History Formdroberts2020-06-16T13:39:14+00:00

Case History Form

Step 1 of 4

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General / Contact Information
Child's Name*
First Middle Last
Nickname
Age
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Lives With
Guardian 1*
First Last
Address*
Address same as child

Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone*
Email*
Guardian 2
First Last
Address
Address same as child

Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone
Email
Billing Email Address (invoices will be sent via email to this address*
Speech, language or learning-related difficulties (or family history of)
SIBLING INFORMATION
Please provide sibling names, ages, and any speech/language or learning difficulties, etc.
Other individuals living in the home
Other languages spoken in the home

History
BIRTH HISTORY
Please provide information on child’s birth history including: pregnancy, duration of labor, delivery method, medications, precautions or special care taken, etc.
MEDICAL HISTORY
Pediatrician
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of last physical
MM slash DD slash YYYY
Results
Date of last Hearing Screening
MM slash DD slash YYYY
Results
Date of last Vision Screening
MM slash DD slash YYYY
Results
Has your child ever been given a medical diagnosis? If so, what?
Allergies (please note reactions to allergies if applicable)
Current Medications
Please provide any information pertinent to checked items
Hospitalizations
OTHER PROFESSIONALS WORKING WITH YOUR CHILD
Professional 1
Phone
Professional 2
Phone
Professional 3
Phone
Previous evaluations or reports
Max. file size: 64 MB.

Development
MOTOR DEVELOPMENT (note age of)
Sat Up
Crawl
Walk
Jump (2 Foot)
Potty Trained
Check if appropriate
- Trips or falls easily
- Difficulty grasping items
- Fear of heights
- Clumsy
- Afraid of climbing
FEEDING DEVELOPMENT (note age of)
Breast-fed
Drinking from a bottle
Drinking from a cup
Using utensils
Eating table food
Does your child have difficulty sucking, swallowing, chewing, drinking from a cup, from a straw, eating different textures (Explain)
Strong food preferences?
Avoids or dislikes certain foods
Food allergies
SPEECH AND LANGUAGE DEVELOPMENT (note age of)
Babbling (bababa)
Jargon (linking babbling together)
First Words
Combining words
Any time at which your child's speech and language or learning development regressed or ceased? (Explain)
% to family
% to others
Please describe current concerns related to speech, language or learning development
Has the child had a speech and language evaluation previously? If yes, please note the place and findings.
Has the child had a speech and language therapy in the past? If yes, please note the place and length of treatment.
Is the child aware of difficulties he/she may be experiencing?
PSYCHOLOGICAL AND NEUROLOGICAL DEVELOPMENT
Has your child had a psychological assessment? (If yes, please note reason, date and place and a brief summary )
Has your child had a neurological evaluation? (If yes, please note reason, date and place and a brief summary )
Please check all that apply
- Nervous
- Wets bed
- Withdrawn
- Destructive
- Head banging
- Anxiety
- Short attention span
- Hyperactive
- Nightmares
- Shy
- Aggressive
- Swaying
- Sensitive to sound
- Sensitive to being touched
- Sleepless
- Sad
- Easily upset
- Temper Tantrum
- Tics
- Underreactive to Sound
- Underreactive to Being Touched
- Fearful of new situations, people,...
- Preservative behaviors (doing so...)
EDUCATIONAL DEVELOPMENT
Current Grade
Teacher
School
Previous Schools Attended
Specific concerns regarding school
Special services received at school
Special services received outside of school
Child's attitude toward school and learning new things
What are you hoping to gain/explore from evaluation or therapy?
Please note any concerns or related issues not covered in this case history

Insurance / Terms of Service
INSURANCE INFORMATION

In order to submit claims for insurance reimbursement, we will need the following information:
Do you have insurance
- I have insurance
Name of Insurance Company*
Name of Insured ( Policy Holder )*
Date of Birth for Insured ( Policy Holder )*
MM slash DD slash YYYY
Policy or authorization number*
Front copy of the insurance card*
Max. file size: 64 MB.
Back copy of the insurance card*
Max. file size: 64 MB.
Front copy of the credit card*
Max. file size: 64 MB.
Back copy of the credit card*
Max. file size: 64 MB.
Please only submit horizontal JPEG images.
Untitled*
- I acknowledge by uploading my credit card information I give permission to MFST to charge my credit card all balances due such as copayments, deductibles, late charges, program fees
FINAL INFORMATION

It may be helpful to keep a 2 day log of foods your child eats and bring this information to your first appointment.
Who were you referred by?
Preferred therapy days:
Preferred therapy times:
Please Review the 4 documents listed below.
Please Review Miracle Farm Speech Therapy's Terms of Agreement
Terms of Agreement Release*
- I have reviewed and accept Miracle Farm Speech Therapy's Terms of Agreement
Please Review Miracle Farm Speech Therapy's Informed Consent and Treatment Form
Consent and Treatment Form Release*
- I have reviewed and accept Miracle Farm Speech Therapy's Informed Consent and Treatment Form
Please Review Miracle Farm Speech Therapy's Liability Release
*
- I hereby acknowledge this consent form gives MFST authorization to audio record my child to aid in evaluation and therapy services for him/her.
Consent to Liability Release*
- I have reviewed and accept Miracle Farm Speech Therapy's Liability Release detailed in the document above.
Please Review Miracle Farm Speech Therapy's Cancellation Policy
Cancellation Policy*
- I have reviewed and accept Miracle Farm Speech Therapy's Cancellation Policy detailed in the document above.
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603.918.1298 ~ [email protected]
eFax# 603.658.2544

MFST NEW CANCELLATION POLICY | Liability Release 122823 intake | © 2024 Miracle Farm Speech Therapy | ALL RIGHTS RESERVED | Developed by: SIY Communications

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