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Case History Form2017-08-01T15:08:54+00:00

Case History Form

Child's Name *





Birth Date *

Address *





Lives With

Guardian 1*


Address*

Address same as child










Guardian 2


Address

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)


SIBLING INFORMATION

Child 1




Child 2




Child 3




Other individuals living in the home

Other languages spoken in the home


BIRTH HISTORY

Describe your pregnancy and delivery:

Medications Taken during pregnancy or labor






NormalInducedC-Section

List any special care of precautions taken (bed rest, oxygen, jaundice, etc.)


MEDICAL HISTORY







Date of last physical

Results

Date of last Hearing Screening

Results

Date of last Vision Screening

Results

Has your child ever been given a medical diagnosis? If so, what?

Allergies (please note reactions to allergies if applicable)

Current Medications


Frequent coldsHearing lossMonoCerebral PalsyOtherFrequent Respiratory InfectionsChicken PoxSpinal MeningitisTraumatic brain damageFrequent ear infectionsExcessively high feversEpilepsySeizures

Please provide any information pertinent to checked items

Hospitalizations


OTHER PROFESSIONALS WORKING WITH YOUR CHILD

Professional 1


Professional 2


Professional 3



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...)


EDUCATIONAL DEVELOPMENT



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 INFORMATION

In order to submit claims for insurance reimbursement, we will need the following information:





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:

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.

I agree