Intake Forms "*" indicates required fields Step 1 of 13 7% This field is hidden when viewing the formIntake TypeFamily InformationChild's Name* First Last NicknameBirth Date:* MM slash DD slash YYYY Sex Male Female Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Primary LanguageOther Languages SpokenSiblings (names/ages)With whom does child live most of the time?* Biological Mother Biological Father Step Mother Step Father Adoptive Mother Adoptive Father Grandparents Other With whom does child live most of the time? (please specify)* 1st Parent InformationName* First Last Email* Mobile Phone*2nd Parent InformationName First Last Email Mobile Phone Referring InformationWho referred you for therapy services?How did you learn about this office?What are your primary concerns/goals regarding your child?*When did you first have those concerns?What do you see as your child’s strengths?*In one sentence, how would you describe your child?Do you have any additional information that will help to better understand your child? School HistoryCurrent SchoolDistrictPresent GradeHand Preference Right Hand Left Hand Is your child in a special class or receiving any support services (please specify)?What does the teacher say about your child? Intervention History - Previously Received ServicesDevelopmental Pediatrician Currently Previously Developmental Pediatrician facility and/or specialist nameNeurologist Currently Previously Neurologist facility and/or specialist nameDevelopmental Optometrist Currently Previously Developmental Optometrist facility and/or specialist nameEarly Intervention Currently Previously Early intervention facility and/or specialist nameOccupational Therapist Currently Previously Occupational therapist facility and/or specialist nameSpeech and Language Pathologist Currently Previously Speech and language pathologist facility and/or specialist namePhysical Therapist Currently Previously Physical therapist facility and/or specialist nameBehaviorist Currently Previously Behaviorist facility and/or specialist nameOrthopedist Currently Previously Orthopedist facility and/or specialist namePsychologist / Counseling Currently Previously Psychologist / counseling facility and/or specialist nameFeeding Therapist Currently Previously Feeding therapist facility and/or specialist name Medical HistoryAny difficulties during pregnancy or delivery? (please specify)Length of PregnancyLength of LaborBirth WasNormalCesareanBreechTwins or moreBirth WeightDid baby require assistance in starting to breathe? Yes No Were there any complications/problems in early infancy?Were there any feeding difficulties in early infancy? Who is your child’s present physician?Does your child have a diagnosis?* Yes No Please specify diagnosis and who diagnosed the child*Referral - If you have a physician referral, please upload a copy. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 128 MB. Does your child have now or in the past had significant health concerns? (please explain)(Surgery, hospitalization, respiratory, lung, or bronchial difficulties, cardiac problems, ear infections, allergies, seizures)Is your child currently on any medications?* Yes No Please specify medication currently taking*Please specify any previously tried medicationsDoes your child have any allergies?* Yes No Please list allergies*Is your child currently taking supplements? (please specify)Does your child use any specialized equipment? (please explain)Is your child currently on a specific diet? (please specify)Has your child had a hearing evaluation?* Yes No Hearing evaluation results*Please specify if results are within normal limitsHas your child had a vision evaluation?* Yes No Vision evaluation results*Please specify if results are within normal limitsHas your child had a psychological evaluation?* Yes No Psychological evaluation results*Please specify if results are within normal limitsHas your child had a neurological evaluation?* Yes No Neurological evaluation results*Please specify if results are within normal limits Developmental HistoryWhen did your child first. (indicate “not yet” if they have not yet accomplished it)Head ControlReaching for objectsRoll over both waysFinger FeedingSit AloneEating with SpoonCreeping on all FoursRide a BikeDrawing a CirclePull to StandCutting with ScissorsWalkUsing knife for cuttingJumpPointing to Simple PicturesHop on One FootDoes your child have difficulty learning new motor skills?LanguageSaid First WordCombined WordsFollowing One-Step CommandsSpoke SentencesFollowing Several-Step CommandsLooking When CalledLooks in Direction Others PointSelf-HelpPut on Shirt IndependentlyButton IndependentlyZips IndependentlySnaps IndependentlyDresses Self IndependentlyTies Shoes IndependentlyBathing IndependentlyCombing HairToilet Trained: BowelToilet Trained: BladderToileting Independently Describe Your Child as an InfantCried a lot, fussy, irritable Yes No Sometimes Non-Demanding Yes No Sometimes Alert Yes No Sometimes Quiet Yes No Sometimes Passive Yes No Sometimes Active Yes No Sometimes Liked Being Held Yes No Sometimes Resisted Being Held Yes No Sometimes Floppy When Held Yes No Sometimes Tense When Held Yes No Sometimes Good Sleep Patterns Yes No Sometimes Irregular Sleep Patterns Yes No Sometimes Describe How Often You Observe the Following Behaviors In Your ChildMostly Quiet Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Overly Quiet Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Tires Easily Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Talks Constantly Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Too Impulsive Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Restless Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Stubborn Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Resistant to Changes Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Fights Frequently Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Exhibits Frequent Temper Tantrums Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Clumsy Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Difficulty Separating from Primary Caretaker Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Nervous Habits or Tics Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Falls Often Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Wets Bed Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Wets or Soils Pants Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Has Poor Attention Span Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Frustrated Easily Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Has Unusual Fears Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Rocks Self Frequently Daily Occurrence Weekly Occurrence Past Occurrence Not Observed Comments Occupational HistoryFor the following questions, please describe your child's abilities, interests, motivations, and your concerns for each activity.Taking Care of Self(dressing, bathing, managing belongings, etc.)Having MealsSleeping PatternsSchool / WorkDoing Community Activities(parks, restaurants, shopping, etc)Play - Using ObjectsPlay - Interaction with Other PeopleWhat motivates your child best?What are your child’s favorite activities, TV shows, videos, music?Does your child play these favorite toys/activities with other children, parents, or alone?Please check all that apply Other Children Parents Alone What are your child’s least favorite toys/activities?How does your child relate to his/her siblings?do they play together/what do they playDoes your child show interest in other children? Yes, shows interest in other children No, prefers to play by him/herself How does your child show that interest?Is your child involved in any community activities?(i.e. sports teams, Boy Scouts, Girl Scouts, etc.)Is there a time of day that is difficult for your child?(i.e. naptime, meal time, morning, evening, bedtime, etc.) Please describe.What time of day is easiest for your child?If and when you discipline your child, what do you do?Describe a typical day for your child from waking till bedtime including whether it is difficult for your child to get to sleep at night and stay asleep. Previous Reports or Progress NotesIf you have any previous reports or progress notes to share, please upload these here.Select File(s) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 128 MB. ConsentsConsent for Therapy Services and Use of Therapy Equipment*I understand that my child will be involved in therapeutic activities which may involve the use of specialized equipment such as suspended swings, bolsters, large therapy balls, climbing structures, scooter boards, tactile or touch media, fine motor, oral motor, and eye-hand coordination activities. I understand that the dangers associated with playing on these types of equipment are similar to those of playing on a playground. I give permission that my child may engage in the use of the various therapeutic activities described above. I understand that Tumble N' Dots is a teaching facility and I give permission for students to observe my child's therapy with a licensed therapist present. I agree to the Consent for Therapy Services and Use of Therapy Equipment policy.Consent for Emergency Medical Treatment*In case of an emergency and if I am not present, I give permission to Tumble N' Dots the authority to consent to any x-ray examination, anesthetic, medical or surgical treatment and hospital care to be rendered under the supervision and upon the advice of a consulting physician or surgeon. In the event of a medical emergency and I, the child’s parent or guardian, am not on site, I hereby understand that Tumble N’ Dots will contact 911 or other appropriate medical personnel. If an ambulance must transport my child, I understand that it will be to the closest medical facility able to handle the situation. Tumble N' Dots will not be held liable for any first aid treatment, medical or hospital care rendered, or drugs, medicine or surgical procedures performed pursuant to this consent. I agree to the Consent for Emergency Medical Treatment policy.Use of Materials Policy*Please be informed that all materials provided to you during our sessions are proprietary and copyrighted to Tumble N' Dots. They are intended solely for your personal use and should not be shared or utilized for commercial purposes or with any third-party providers. Your understanding and cooperation in respecting these terms are greatly appreciated. I agree to the Use of Materials Policy.Cancellation Policy*We strive to implement this policy in a reasonable fashion and take into consideration the somewhat unpredictable nature of working with children. If you need to cancel an appointment, please notify the office by completing the following form: https://TumbleNDots.com/cancel/ Cancellations should be made at least 24 hours before the appointment. Please do not send SMS/TXT messages to the office and please do not email the therapist with a cancellation request. In order for progress to be made, all scheduled sessions must be attended. If you are unable to keep an appointment, it is extremely important that you schedule a make-up session as soon as possible. Staffing and facility expenses are incurred when we make appointments available to you with our staff. Giving advance notice of a cancellation allows time for others who need services to reserve the appointment time instead. Please be courteous and responsible. A "no show" will be charged the full hourly rate per missed appointment. If you must cancel with less than 24-hour notice, we will ask your availability to reschedule the appointment for another in-person appointment time. If an appointment is not rescheduled, your appointment will be charged a fee of the full hourly rate. Should you cancel 25% or more of your scheduled appointments in any 2 consecutive months, we will not be able to hold your scheduled time slot for future appointments. You will need to contact our office to confirm and schedule availability for future appointments. I agree to the Cancellation Policy.Sick Child Policy*In order to provide a safe, healthy environment for all our children, we ask that you keep your child home any time he or she exhibits any of the following symptoms: Fever within the previous 24 hours Vomiting and/or diarrhea within the previous 24 hours Any symptoms of childhood diseases (scarlet fever, measles, mumps, chicken pox, whooping cough, etc.) Runny nose with any colored discharge Excessive coughing Sore throat Any unexplained rash Pink eye Head lice (child should be free of all nits) We require all participants in therapy activities and our therapists to be fever free (less than 99.9 F) for a full 24 hours, without fever-reducing medication, before attending therapy appointments. If your child is being treated with an antibiotic, he or she should have received treatment for at least 24 hours before coming to the clinic. If your child did not attend school due to illness, do not bring them to therapy. Please notify the office by visiting the following link: https://tumblendots.com/cancel/ Thank you in advance for your consideration of this policy! I agree to the Sick Child Policy.Signature* Payment and Billing PoliciesBy signing this policy agreement, you understand and agree to pay the following rates for services.Individual Occupational Therapy (OT), Speech-Language (SLP), or Feeding Therapy services$178 (50 minute)$107 (25 minutes)Community / In Home / School services (up to 10 minutes drive from clinic location)More than 10 minutes drive will have an additional charge for time and travel based on hourly rate.$220 (50 minute hour) Private Evaluation Mod/High Complexity Evaluation/Re-Evaluation Includes: 2 - 3 Standardized measures and clinical observations, 30-minute follow-up consultation with caregivers, and report with recommendations$465 fee Initial Office Consult AppointmentIncludes: 1x1 meeting at the office with the therapist to evaluate and discuss the child's development. The fee will be deducted from the full evaluation fee if a full evaluation is recommended and completed within a month of the consultation appointment$225 fee Hourly RateReports, consultations, IEP meetings, insurance requests, court/subpoena appearances, etc.$178 / hour + travel if applicable "No Show/No Call" feesLess than 24 hour notice - please refer to cancellation policy$178 fee Consent for Payment and Billing Policy*$178 for 50 minute individual Occupational Therapy (OT), Speech-Language (SLP), Feeding Therapy, or Animal Assisted Therapy services. Charged at $107 for 25 minutes individual therapy. $220 for 50 minute Community / In Home / School services up to 10 minutes drive from clinic location. More than 10 minutes drive will have an additional charge for time and travel based on hourly rate. $465 for Private Evaluation at the clinic. $225 for initial consult appointments. Cost will be applied toward evaluation if evaluation is needed. $178 for "No Show/No Call" fees. Less than 24 hour notice - please refer to cancellation policy. Hourly Rate $178 for Reports, ongoing consultations, IEP meetings, subpoenas, and insurance or documentation requests. We do not submit claims directly to insurance companies. As the client, you are responsible for full payment at the time of service, regardless of any pending insurance reimbursement. Payment for private evaluations is due BEFORE the evaluation process begins. Your credit card on file will be charged for the evaluation and/or first therapy session unless a payment via Zelle, check, or cash is received at the office prior to the appointment. Invoices are due upon receipt. Your payment will be processed automatically when we issue the invoice unless your account has a credit balance. Invoices unpaid within fifteen (15) days of the invoice due date shall bear interest from such date at the rate of one percent (1%) per month. We require patients to provide a credit card to keep on file in our secure billing software. Additional reports and consultation meetings will be billed at the current hourly rate. When you or your insurance company REQUEST REPORTS, you will be billed at the hourly rate. We require at least 30 days' notice to cancel or make any major changes to your account. Cancellations must be made in writing, via email or in person, and turned into the office. Tumble N’ Dots reserves the right to increase fees periodically and will inform you by sending a notice to the email address on file at least 30 days in advance of any increase. I agree to the payment and billing policy.Consent for Payment Method*Payment by cash, check, Zelle, debit card, or credit card is accepted. Zelle payment should be sent directly to Hello@TumbleNDots.com. I agree to the payment method policy.Select a preferred payment method* Zelle, check, or cash Debit Card or Credit Card If paying via Zelle, please ensure sending payments directly to Hello@TumbleNDots.com or use the following QR code: Signature*Credit Card Authorization FormWe require to have a credit card on file regardless of payment method selected. Please note that your credit card on file will be used to pay for outstanding invoices if we do not receive a payment before the due date. Overdue invoices will incur a late fee Tumble N' Dots is offering a secure and convenient method of payment of therapy services. Your credit card information is kept confidential and secure. I hereby authorize Tumble N' Dots to automatically charge my credit card for the total balance of therapy services rendered and/or cancellation policies and procedures. I understand that it is my obligation to notify Tumble N' Dots of any changes in the status of this card. I understand that if my preferred payment method is Check, Zelle, or Cash, the debit or credit card on file will be used only if no payment has been received by the due date on the invoice. Cardholder Name*Cardholder Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card Number*MasterCard, Visa, or Discover only. Expiration Date (mm/yy)*CVV Code*Signature*EmailThis field is for validation purposes and should be left unchanged.
