Child's Name *
Birth Date *
Address same as child
Address same as child
Billing Email Address (invoices will be sent via email to this address
Speech, language or learning-related difficulties (or family history of)
Other individuals living in the home
Other languages spoken in the home
Describe your pregnancy and delivery:
Medications Taken during pregnancy or labor
List any special care of precautions taken (bed rest, oxygen, jaundice, etc.)
Date of last physical
Date of last Hearing Screening
Date of last Vision Screening
Has your child ever been given a medical diagnosis? If so, what?
Allergies (please note reactions to allergies if applicable)
Frequent coldsHearing lossMonoCerebral PalsyOtherFrequent Respiratory InfectionsChicken PoxSpinal MeningitisTraumatic brain damageFrequent ear infectionsExcessively high feversEpilepsySeizures
Please provide any information pertinent to checked items
OTHER PROFESSIONALS WORKING WITH YOUR CHILD
MOTOR DEVELOPMENT (note age of)
Check if appropriate
Trips or falls easilyDifficulty grasping itemsFear of heightsClumsyAfraid of climbing
FEEDING DEVELOPMENT (note age of)
Does your child have difficulty sucking, swallowing, chewing, drinking from a cup, from a straw, eating different textures (Explain)
SPEECH AND LANGUAGE DEVELOPMENT (note age of)
Any time at which your child's speech and language or learning development regressed or ceased? (Explain)
INTELLIGIBILITY OF SPEECH (approximate)
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
NervousWets bedWithdrawnDestructiveHead bangingAnxietyShort attention spanHyperactiveNightmaresShyAggressiveSwayingSensitive to soundSensitive to being touchedSleeplessSadEasily upsetTemper TantrumTicsUnderreactive to SoundUnderreactive to Being TouchedFearful of new situations, people,...Preservative behaviors (doing so...)
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
In order to submit claims for insurance reimbursement, we will need the following 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:
Terms of Agreement I hereby authorize Miracle Family Speech Therapy (MFST) to submit a claim to my insurance carrier for all covered services rendered by the therapist and authorize and direct my insurance carrier or its intermediaries to issue payment checks directly to the therapist rendering the covered service. I will be responsible for those charges deemed not covered by said insurance carrier so long as such insurance has not been deemed such services to be medically inappropriate or unnecessary. I also understand that if my insurance company is not a contracted carrier, I am responsible for the full fee charged by my therapist regardless of what my insurance pays. I authorize MFST to furnish complete information to my insurance carrier and its intermediaries regarding the services rendered. I permit a copy of this authorization to be used in the place of the original. I consent to assign all payments for these services to this practice. I understand that I am responsible for all co-payments, amounts applied to deductibles and any coinsurance amounts, as required by my contract with my insurance plan and state regulation. I further understand that my contract with my insurance entity may or may not cover some services. It is my responsibility to obtain information from my health plan about service coverage. If I seek care outside of the contact, I am aware that I may be responsible for all charges that are incurred. If for any reason my insurance plan does not pay for my approved charges in full, I agree to be fully responsible for the amount. I also agree should collections be necessary for payment of my account, to be fully responsible for any collection fees and associated costs.