Pediatric Therapy Services, Inc.

309 Holly Lane w Mankato MN 56001

Phone: (507) 388-KIDS (5437)

Fax: (507) 388-2108

 

 

Thank you for the opportunity to work with your child and you, at Pediatric Therapy Services, Inc. We would like to schedule an appointment for your child. Your information is a valuable part of our intake, scheduling, evaluation and treatment process. Below is a list of 6 documents that must be completed / obtained and returned to Pediatric Therapy Services, Inc., (within two weeks) prior to scheduling your initial appointment. Documents 1 through 4 below are to be obtained and completed by the parent/legal guardian. Pediatric Therapy Services, Inc. will process documents 5 - 6 on behalf of the patient.

 

FORMS TO BE COMPLETED BY PARENT/LEGAL GUARDIAN

 

 

DOCUMENTS TO BE OBTAINED BY PARENT/LEGAL GUARDIAN

 

 

DOCUMENTS TO BE OBTAINED BY PEDIATRIC THERAPY SERVICES, INC.

 

 

Upon completion and return of the necessary information above, we will be able to schedule your initial appointment. You can mail your information to Pediatric Therapy Services, Inc, Attention Scheduling, 309 Holly Lane, Mankato, MN 56001. Or, you can fax your information to (507) 388-2108, attention of Scheduling.

 

Again, we look forward to working with your child and you. If you have any questions or concerns, please call us at 507-388-5437.

Thank you for choosing Pediatric Therapy Services, Inc.

 

 


 

 

 

 

Pediatric Therapy Services, Inc.

309 Holly Lane w Mankato MN 56001

Phone: (507) 388-KIDS (5437)

Fax: (507) 388-2108

 

PATIENT REGISTRATION FORM

 

PATIENT INFORMATION

 

PATIENT NAME: _________________________________________________________________SEX: (M F) DOB: _____-_____-______

                                  LAST                                                    FIRST                                         MI                                        MO     DAY  YR

HOME PHONE: _______________________   SS#: _________-________-________PATIENT #:(OFFICE USE)_______________________

                               

ADDRESS: ______________________________________________________CITY: ______________STATE: ________ ZIP: ___________

 

REFERRING PHYSICIAN: _______________________________PRIMARY CARE PHYSICIAN: _____________________________________

 

REFERRING PHYSICIAN PHONE: ________________________ PRIMARY CARE PHYSICIAN PHONE: ______________________________

 

HOW DID YOU HEAR ABOUT US? Phonebook _____ Website _____ Friend ______ Doctor _______ Other __________________

 

 

RESPONSIBLE PARTY  (PARENT/LEGAL GUARDIAN)

 

NAME: ______________________________________________________________________ DATE OF BIRTH: _______-_______-________

                                  LAST                                                    FIRST                                       MI                                          MO        DAY       YR

SS#: _________-_________-_______________ RELATION TO PATIENT:_________________________________________

 

ADDRESS: ________________________________________________________CITY: ________________STATE: _______ ZIP: _________

 

HOME PHONE: ___________________________ WORK PHONE: ______________________CELL PHONE: ___________________________

                                                                                                                                        

EMAIL ADDRESS: ________________________________________

 

NAME: ______________________________________________________________________ DATE OF BIRTH: _______-_______-________

                                  LAST                                                    FIRST                                      MI                                          MO        DAY       YR

SS#: _________-_________-_______________ RELATION TO PATIENT:_________________________________________

 

ADDRESS: _________________________________________________________CITY: ________________STATE: _______ ZIP: _________

 

HOME PHONE: ___________________________ WORK PHONE: _____________________ CELL PHONE: ___________________________

                                                                                                                                        

EMAIL ADDRESS: ________________________________________

 

 

INSURANCE

 

PRIMARY INSURANCE: ___________________________________POLICY NUMBERS: __________________________________________

                                                                                                                                                                     (ID#)                     (GROUP/PLAN#)

POLICY HOLDER: __________________________________________________EMPLOYER: _______________________________________

                                     LAST                                FIRST                             MI

 

DATE OF BIRTH: ________-_______-________ SS#: _________-_______-______RELATION TO PATIENT:__________________________

                                MO            DAY             YR

 

INSURANCE PHONE: ____________________________________________________

 

SECONDARY INSURANCE: ________________________________ POLICY NUMBERS: __________________________________________

                                                                                                                                                                     (ID#)                     (GROUP/PLAN#)

POLICY HOLDER: _________________________________________________ EMPLOYER: _______________________________________

                                     LAST                                FIRST                             MI

 

DATE OF BIRTH: ________-_______-________ SS#: _______-_______-______ RELATION TO PATIENT:__________________________

                                MO             DAY       YR

 

INSURANCE PHONE: _________________________________ MINNESOTA MA: _____YES _____ NO    ID# _________________________

 

 

RELEASE OF INFORMATION

 

I authorize the exchange of Protected Health Information between Pediatric Therapy Services, Inc., and the specified individuals listed below:

 

PRIMARY DOCTOR/CLINIC:_________________________________________________________ PHONE #: _________________________

 

SPECIALTY DOCTOR.CLINIC: _______________________________________________________PHONE #: _________________________

 

                      ­­­­­­­­­­­­­_____________________________________________________________ PHONE #: _________________________

 

PRESCHOOL/SCHOOL DISTRICT: _____________________________________________________ PHONE #: _________________________

 

SOCIAL WORKER: __________________________________________________________________PHONE #: _________________________

 

OTHER: __________________________________________________________________________ PHONE #: _________________________

             

               __________________________________________________________________________ PHONE #: _________________________

 

 

 

OTHER CONTACTS

 

Please list other individuals who are involved in taking care of the patient, such as caregiver and/or relative other than guardian, with whom you authorize Pediatric Therapy Services, Inc. to discuss/exchange information regarding the patient’s treatment.

 

NAME: _________________________________________________________________RELATION TO PATIENT: ______________________

               LAST                                                     FIRST                                          MI

 

HOME PHONE: __________________________ CELL PHONE: ____________________

 

 

NAME: _______________________________________________________________ RELATION TO PATIENT: ______________________

               LAST                                                     FIRST                                          MI

 

HOME PHONE: __________________________ CELL PHONE: ____________________

 

 

NAME: _________________________________________________________________RELATION TO PATIENT: ______________________

               LAST                                                     FIRST                                          MI

 

HOME PHONE: __________________________ CELL PHONE: ____________________

 

 

 

 

AUTHORIZATIONS and ACKNOWLEDGEMENTS

 

I have received the Notice of Privacy Practices from Pediatric Therapy Services, Inc.

 

SIGNATURE:  X _______________________________________________________________ DATE: _______________

                              Parent/Legal Guardian

 

I hereby authorize PEDIATRIC THERAPY SERVICES, INC. to furnish information concerning treatments to INSURANCE CARRIERS, PHYSICIANS, and THERAPISTS AND/OR OTHER PERSONNEL, who are involved in taking care of the patient. I authorize payment of any medical benefits to PEDIATRIC THERAPY SERVICES, INC. I certify that the above information is correct and that I AM RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED. I permit a copy of this authorization to be used in place of the original.

 

SIGNATURE:  X _______________________________________________________________ DATE: _______________

                              Parent/Legal Guardian

 

 

 

 

 

Pediatric Therapy Services, Inc.

 

PATIENT SERVICE AGREEMENT

 

Name of Patient: _____________________________________________ DOB: _______________

 

  1. Our fees for services are billed on a monthly basis. The statement will contain a complete itemization of charges and will reflect payments to date. All charges are due and payable within 30 days of receipt. Please discuss any concerns with the business office.

  2. It is the parent(s)/legal guardian responsibility to inform Pediatric Therapy Services, Inc. of any and all changes in insurance information, including group policy number, identification number, phone numbers, address, etc. as soon as possible. Failure to do this could result in total patient responsibility for charges incurred.

  3. If an emergency should occur during treatment, we will call 911 if there is an emergency unless a certified copy of a Do Not Resuscitate (DNR) order has been given to Pediatric Therapy Services, Inc.

  4. It is a courtesy of Pediatric Therapy Services, Inc. to allow parents/legal guardians or caregivers to leave the premises during their child’s appointment. If leaving the premises, we ask that you leave cell # or take a pager (provided by us); in cases you are needed back before the end of the session. However, it is very important to be back on the premises 10 minutes before the patient’s appointment is scheduled to end so the therapist can discuss treatment with the parent/legal guardian or caregiver. If your child has a history of unstable medical or behavior conditions, you or a trained caregiver will be required to stay in the clinic during your child’s treatment session(s). This will be determined by the treating therapist.

  5. Children can not be left unattended in the waiting room. All children must wait in the reception area until a parent/guardian or responsible party picks them up. For safety reasons, children will not be permitted to leave the clinic to wait at the door for their ride.

  6. Health Policy: If your child is sick and/or contagious within the last 24 hours of scheduled appointment or did not attend school the day of the appointment, please keep your child at home. If your child is sick he/she will be sent home. If prescription medication is required for treatment of illness, your child must receive the medication for 24 hours prior to scheduled session.

  7. An agreement has been made between therapist and parent/legal guardian regarding frequency of therapy. This frequency has been determined to be most beneficial in order to maximize the therapeutic effect of treatment. When the need arises to cancel an appointment, we request notification as soon as possible. After 3 consecutive “no shows” or cancels your child will be removed from the current therapy schedule. Parents are asked to call and reschedule therapy sessions.

  8. The staff at Pediatric Therapy Services, Inc. includes licensed therapists as well as therapist assistants. Licensed therapists complete all evaluations and treatment plans. Your child may be seen by a therapist assistant if deemed appropriate by the evaluating therapist. Your child’s therapy sessions will be scheduled based on available time slots and on therapist availability in the schedule.

  9. Pediatric Therapy Services, Inc. occasionally provides tours of the facility during treatment hours to prospective patients, parents, vendors, physicians, employee candidates and therapy students/volunteers. PTS, Inc. has video cameras in three treatment rooms, Blue Room, Green Room and New Evaluation Room. Parent/guardian or caregivers will be allowed to view treatment sessions, determined by the treating therapist. PTS, Inc. occasionally videotapes/photographs for lecture, training, webpage and/or marketing. 

 

I give PTS, Inc. permission to photograph/videotape my child for the following purposes:

 

                  Lecture/training: Yes/No                        Webpage: Yes/No                                  Marketing: Yes/No

 

 

_______________________________          __________           ________________________________       ________

Parent/Legal Guardian                                            Date                           PTS, Inc Representative                                     Date

 

Pediatric Therapy Services, Inc.

309 Holly Lane w Mankato MN 56001

Phone: (507) 388-KIDS (5437)

Fax: (507) 388-2108

 

INTAKE QUESTIONNAIRE

 

Thank you for taking the time to fill out this questionnaire regarding your child.  This information will better help us determine your child’s strengths and weaknesses prior to the evaluation.  If you have any questions please call 507-388-5437.  Thank you.

 

Name:___________________________________________________________             DOB:__________________

Child’s Diagnosis:_________________________________________________________________________

Person completing this form:_________________________________________________________________

School attending/PT/OT/ST:_________________________________________________________________

If your child receives school services, please bring a copy of your child’s IEP.

Daycare:_________________________________________________________________________________

Any other special services received:___________________________________________________________

Siblings/Pets:_____________________________________________________________________________

What are your child’s strengths?______________________________________________________________

What are your child’s interests?_______________________________________________________________

 

Please indicate if your child has a history of any of the following?

Medical History Yes No Please list current/regular Medications:
Ear Infections    
Ear Tubes    
Needs hearing aids     Birth History Yes No

Hearing evaluation completed?  When?

     Was pregnancy full term?    
Serious illness or injury     Any medications taken during pregnancy?    
Frequent colds or sinus problems     Any complications with delivery?    
Need for eye glasses     Any special care  required at birth (i.e. oxygen, intubation)    
Allergies     Comments:
Upper respiratory infections     Comments:
History of car sickness     Comments:
Asthma      
Genetic disorder  

 

Please circle any concerns you have about your child’s development:

 

Understanding directions                               Overall Coordination                                 Social Skills/Interaction with others

Understanding what they say                        Attention                                                    Play Skills

Ability to express themselves                        Independence with self-cares                 Fine motor skills            

Stuttering                                                           Feeding/Picky eater                                  Oral Motor Skills                                               

Not Talking                                                        Sensory Issues                                          Behaviors

                                                           

Please circle any behaviors that your child may exhibit:

 

Refusal to do difficult tasks                         Hitting or throwing items                    Shutdowns

Tantrums                                                         Difficulty separating                            Refusal to imitate

Short attention                                               Others: _______________________________

__________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

Occupational Therapy Questions:

 

Self Care skills:

    1.  Does your child need help with dressing?  Yes/No

    2.  Can your child complete snap, zippers, and buttons? Yes/No

    3.  Can your child pick out his/her own clothing? Yes/No

    4.  Does your child take showers or baths?

    5.  Does your child know and follow morning or evening routines with few reminders?  Yes/No

    6.  Is your child rigid about his/her routine? Yes/No

 

Sensory:

1.  How does your child respond to a change in environments such as going to school, or visiting friends or                     relatives?

2.   Does your child respond negatively to busy environments such as grocery store or mall? Yes/No

3.  Are their certain textures that bother your child (clothing, tags, toothpaste, foods, grass, sand)? Yes/No

 

Attention:

  1. Does your child understand simple routine directions (sit down, come here)?  Yes/No
  2. Can your child follow multiple step directions (pick up your toys and put them away)?  Yes/No
  3. When looking at a book or pictures, do they show interest or interaction with story characters in the book?  Yes/No
  4. How long will they sit for a story?  5 min   10 min                         15 min

 

 

 

 

Speech and Language Questions

 

Please circle any concerns you have about your child’s speech and language development:

Understanding    directions                          Ability to express themselves                     Not Talking

Understanding what they say                     Stuttering                                                      Social Skills

Feeding                                                        Oral Motor Skills

 

Speech:

Does your child words to communicate? If no, move on to Receptive Language.

 

How much of the time do you understand your child’s talking?

0-25%                 25-50%                           50-75%                           75-100%

 

Do you understand more or less as sentence length increases?

 

Receptive Language:

Does your child look at the person who is talking to him or her?       Yes/No

Does your child understand simple routine directions (sit down, come here)?  Yes/No

Does your child respond to words like “stop” or “wait”?  Yes/ No

 

Expressive Language:

Does your child try to gain your attention to show you things?  Yes/ No

Does your child use more words or gestures to let you know what he or she wants? 

A. Words                       B.  Gestures

 

Does your child use words to:

Ask for something he/ she wants to do or for a desired object?  Yes/ No

Ask for help?  Yes/ No

 

Social Skills:

Is your child able to easily:

a. Making friends?  Yes/ No                           b. Keeping Friends?  Yes/ No

Does your child participate in pretend play?  Yes/ No

Does your child play with peers?  Yes/ No

Does your child use eye contact?  Yes/No

 

Feeding/Oral Motor:

1. Does your child cough when drinking or eating?  Yes/No

2. Does your child put toys/objects in his or her mouth?      Yes/No

3. Does your child drool?  Yes/No

4. Is your child a picky eater?  Yes/No

5. Does your child use a spoon or fork independently?  Yes/No

 

List 3 meats that your child will eat:

List 3 breads/starches that your child will eat:

List 3 vegetables/ fruits that your child will eat:

 

 

Anything else you would like to share about your child’s communication, skills or development?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

**Please print these forms and send them to:

309 Holly Lane

Mankato, MN 56001

 

or fax them to:

507-388-2108

 

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________