Intake Forms "*" indicates required fields Step 1 of 13 7% Family InformationChild's Name* First Last Nickname Birth 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 Language Other Languages Spoken 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* Phone*(Optional) Sign up for our newsletter? Yes, please add my email address to your newsletter list. 2nd Parent InformationName First Last Email 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 School District Present Grade Hand 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 name Neurologist Currently Previously Neurologist facility and/or specialist name Developmental Optometrist Currently Previously Developmental Optometrist facility and/or specialist name Early Intervention Currently Previously Early intervention facility and/or specialist name Occupational Therapist Currently Previously Occupational therapist facility and/or specialist name Speech and Language Pathologist Currently Previously Speech and language pathologist facility and/or specialist name Physical Therapist Currently Previously Physical therapist facility and/or specialist name Behaviorist Currently Previously Behaviorist facility and/or specialist name Orthopedist Currently Previously Orthopedist facility and/or specialist name Psychologist / Counseling Currently Previously Psychologist / counseling facility and/or specialist name Feeding Therapist Currently Previously Feeding therapist facility and/or specialist name Medical HistoryAny difficulties during pregnancy or delivery? (please specify) Length of Pregnancy Length of Labor Birth WasNormalCesareanBreechTwins or moreBirth Weight Did 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 problems? (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 medicationsIs 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 limits Has your child had a vision evaluation?* Yes No Vision evaluation results*Please specify if results are within normal limits Has your child had a psychological evaluation?* Yes No Psychological evaluation results*Please specify if results are within normal limits Has 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 Control Reaching for objects Roll over both ways Finger Feeding Sit Alone Eating with Spoon Creeping on all Fours Ride a Bike Drawing a Circle Pull to Stand Cutting with Scissors Walk Using knife for cutting Jump Pointing to Simple Pictures Hop on One Foot Does your child have difficulty learning new motor skills? LanguageSaid First Word Combined Words Following One-Step Commands Spoke Sentences Following Several-Step Commands Looking When Called Looks in Direction Others Point Self-HelpPut on Shirt Independently Button Independently Zips Independently Snaps Independently Dresses Self Independently Ties Shoes Independently Bathing Independently Combing Hair Toilet Trained: Bowel Toilet Trained: Bladder Toileting 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 Your Child at PresentMostly Quiet Daily Problem Weekly Problem Past Problem Not a Problem Overly Quiet Daily Problem Weekly Problem Past Problem Not a Problem Tires Easily Daily Problem Weekly Problem Past Problem Not a Problem Talks Constantly Daily Problem Weekly Problem Past Problem Not a Problem Too Impulsive Daily Problem Weekly Problem Past Problem Not a Problem Restless Daily Problem Weekly Problem Past Problem Not a Problem Stubborn Daily Problem Weekly Problem Past Problem Not a Problem Resistant to Changes Daily Problem Weekly Problem Past Problem Not a Problem Fights Frequently Daily Problem Weekly Problem Past Problem Not a Problem Exhibits Frequent Temper Tantrums Daily Problem Weekly Problem Past Problem Not a Problem Clumsy Daily Problem Weekly Problem Past Problem Not a Problem Difficulty Separating from Primary Caretaker Daily Problem Weekly Problem Past Problem Not a Problem Nervous Habits or Tics Daily Problem Weekly Problem Past Problem Not a Problem Falls Often Daily Problem Weekly Problem Past Problem Not a Problem Wets Bed Daily Problem Weekly Problem Past Problem Not a Problem Wets or Soils Pants Daily Problem Weekly Problem Past Problem Not a Problem Has Poor Attention Span Daily Problem Weekly Problem Past Problem Not a Problem Frustrated Easily Daily Problem Weekly Problem Past Problem Not a Problem Has Unusual Fears Daily Problem Weekly Problem Past Problem Not a Problem Rocks Self Frequently Daily Problem Weekly Problem Past Problem Not a Problem 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 play Does 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.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$170 (50 minute hour)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.$198 (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$450 fee High Complexity Evaluation/Re-EvaluationIncludes: Performance testing (SIPT), one-hour follow-up consultation with caregivers, and report with recommendations$950 fee Hourly RateReports, consultations, IEP meetings, insurance requests, etc.$170 / hour "No Show/No Call" feesLess than 24 hour notice - please refer to cancellation policy$170 fee - Your first therapy session will be charged BEFORE your scheduled appointment. - 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 evaluation. Payment by cash, check, Zelle, or credit card is accepted. Zelle payment should be sent directly to Hello@TumbleNDots.com. Invoices are due within fourteen (14) days. If you selected Credit Card as a preferred payment method, your payment will be processed automatically when we issue the invoice. For all other payment methods, if we do not receive your payment before the due date, your credit card on file will be charged for your account 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. Tumble N' Dots requires patients to provide a credit card to keep on file in our secure billing software. If you prefer to pay for services via cash, check, or Zelle, please mark it below. 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. Tumble N’ Dots reserves the right to increase fees periodically and will inform you at least 60 days in advance of any increase. Signature*Credit Card Authorization FormTumble 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 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* Expiration Date (mm/yy)* CVV Code* Signature*EmailThis field is for validation purposes and should be left unchanged.
