Family Background
Address 1 *
Address 2
Email *
Parents/Caregivers/Legal Guardians
Siblings
Who currently lives with the child at home
What is the primary language spoken at home
Is any language other than English spoken in the home NoYes
If Yes please list the languages
Please list mothers significant health issues/complications during pregnancy/delivery
Please list childs significant health issues/complications during pregnancy/delivery
Medical History
Please list any current medications
List any frequently occurring medical problems
List any significant illnesses injuries or hospitalizations
Is your child up to date on vaccinations/immunizations? YesNo
If not, please explain:
Auditory, Speech and Language
How does your child usually communicate? (eg. gestures single words phrases sentences)
Please describe your childs auditory speech and/or language difficulties.
Has your children been previously evaluated for speech and language? -- Select Yes or No --YesNo
Performed by:
Results:
Has your child previously received speech and language treatment? -- Select Yes or No --YesNo
Provided by:
Have any other specialists (physicians, audiologists, psychologists, special education teachers, etc.) seen your child? If yes, indicate the type of specialist, when the child was seen and what the conclusions were.
Overall Skill Development
Please indicate how you feel about your child’s behavior/development in the following areas:
Gross Motor Below AverageAverageAbove Average
Description:
Fine Motor Below AverageAverageAbove Average
Feeding/Swallowing Below AverageAverageAbove Average
Description
Social Interaction Below AverageAverageAbove Average
Vision Below AverageAverageAbove Average
Hearing Below AverageAverageAbove Average
Self-Help Skills Below AverageAverageAbove Average
Description Skills
Educational History
Name of school
School Address
Grade / Level
Teacher
Is your child on a 504 Plan IEP or IFSP -- Select Yes or No --YesNo
Authorized Signature Release Form Please read the Island Wide Speech Authorized Signature Release Form
I have read and agreed to the Island Wide Speech Authorized Signature Release Form. I agree
I have read and agreed to the Attendance Policies and Sick Procedures at Island Wide Speech. I agree
I have read and agreed to the Teletherapy Consent Form for Island Wide Speech. I agree
I have read and agreed to the HIPAA Notice of Privacy Practices for Island Wide Speech. I agree
I understand it is my choice to attend sessions at Island Wide Speech either through insurance or private pay.
-- Please select one --I opt to go through my health insurance for all services at Island Wide Speech.I opt to pay privately for all services at Island Wide Speech. I am choosing not to go through my health insurance.
Insurance Policy Questions
Please read the Insurance Policy Questions to ask your Insurance questions
If attending via insurance, I agree to call my provider and ask the above questions in regards to my policy’s coverage of speech therapy. I agree
I understand that if my insurance denies reimbursement for claims submitted by Island Wide Speech, I will be responsible for all outstanding claims/payments. I agree
Please select your primary insurance: -- Please select one --CignaEmblemHealth - GHIEmpire BlueCross BlueShieldMagnacareMedicareOscarThe Empire Plan: NYSHIPUnitedHealthcareOther
Upload Insurance Card Please send us a copy of the front and back of your insurance card.
Do you have a secondary insurance? YesNo
Please select your secondary insurance: -- Please select one --CignaEmblemHealth - GHIEmpire BlueCross BlueShieldMagnacareMedicareOscarThe Empire Plan: NYSHIPUnitedHealthcareOther
Secondary Member ID:
Secondary Group ID:
Upload Secondary Insurance Card Please send us a copy of the front and back of your secondary insurance card.
Upload your Prescription.
Please sign
Name of person completing form *
Relationship to client *
Please sign below: *
Back
Island Wide Speech · fara@islandwidespeech.com · (516) 415-2751 · Plainview, NY