Intake Forms

All Intake Forms must be completed before your first scheduled appointment. Intake forms are available here.

The filled intake packet includes information about the family, environment, medical history, school history, intervention history, developmental history, and family impact.

Cancellations and Missed Appointments

Individual Therapy Sessions

We strive to implement this policy in a reasonable fashion and take into consideration the somewhat unpredictable nature of working with children.

If it is necessary to cancel an appointment, please notify the office as soon as possible. Cancellations should be made at least 24 hours before the appointment.

Subject to therapist availability, if we are able to reschedule your appointment for that same week, we will waive the No Show fees. However, if the therapist is not given sufficient notice (at least 24 hours) and we are unable to reschedule, a No Show charge will be applied to your account.

If the child needs to stop therapy for any length of time, his/her regularly scheduled time cannot be promised upon return.

Policy Regarding Insurance Reimbursement

Occupational Therapy and Speech Therapy are covered services under flexible spending account.

Tumble N’ Dots is a private pay clinic and is not part of any insurance network.

We do provide super bills for potential reimbursement that you can submit to your health insurance carrier or FSA account as an out-of-network provider.

The child’s family is responsible for all services rendered. If you wish to pursue possible reimbursement from your insurance company for an out-of-network provider, please provide us with the following to be included with your invoice:

  • Letter of referral or prescription for services from the referring physician
  • DSM-IV or ICD-10 diagnosis and code number (designated by the physician)

This information will enable us to provide an invoice that is in keeping with your health insurance company’s invoice policies.

To facilitate processing of reimbursement claims we provide our patients with a receipt for services (a superbill) that includes all information needed to submit a claim to your insurance company. It is not guaranteed that services provided will be covered by your specific insurance plan. For information about reimbursement rates, contact your insurance provider about your specific out-of-network benefits. Here are some helpful questions to ask your health insurance representative to clarify your out-of-network benefits:

  • Does my coverage include mental health services?
  • Does my coverage include seeing an out-of-network provider
  • What is my deductible and must it be met before services are covered?
  • What is the amount of coverage per therapy session?
  • Do I need a referral from my primary care physician to access my out-of-network benefits?

We will be happy to schedule a call with your pediatrician to discuss our findings during the evaluation process and consult on our recommendations.

Please remember that payments are due at the time of receipt regardless of delays in reimbursement by insurance providers.

Billing questions

If you have any questions related to billing please contact our office.

Timely Payments

For individual therapy, we will issue an invoice for services twice a month. If you provided your credit card information for your account, we will charge the card on file when the invoice is issued. A detailed receipt will be emailed to you and a copy of the paid invoice.

Payment is considered delinquent if not paid within 2 weeks.

Accounts that are past due will necessitate discontinuation of therapy.

If your child is being evaluated for services, we require full payment prior to the assessment.

If your child is being seen at the clinic for the first time, we require full payment at prior to the appointment.

In the event that your check is returned due to insufficient funds or your credit card is declined, you will have 7 days from the time you are notified to make alternative payment arrangements. You will be responsible for any bank fees or charges incurred due to the returned check.

[Date updated: February 13th, 2023]