Intake Questionnaire Step 1 of 4 – About 25% Client Name:(Required) First Last Client Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:(Required) M F Medical Diagnosis and Date of Onset (if Applicable) Reason for referral:(Required) Person Completing Form(Required) First Last Relationship to child Email Address(Required) Medical HistoryPrenatal History Surgeries/Procedures: Medications: Allergies:(esp. bee stings, pollens, dust) Milestone HistoryRolled Over Age Comments Sitting Age Comments Belly crawl Age Comments Creeping on hands & knees Age Comments Pull to stand Age Comments Cruise (holding onto things) Age Comments Walking Age Comments First Words Age Comments Speak in sentences Age Comments Managed snaps, zippers, buttons Age Comments Was the crawling phase brief or absent? Did your child experience hesitancy or delays in learning to go down the stairs? Other developmental concerns: Functional & Environmental HistoryPriorities and Reason for ReferralList current concerns or specific challenges your child is having: Are there any strategies that have worked well so far? Effected areas of functionAuditoryhearing aides, auditory defensiveness or sensitivity Yes No Comments Vision Yes No Comments Oral Motor/Language Yes No Comments Social Skills/Behaviors Yes No Comments Sensory Processing Yes No Comments Activities of Daily Livingdressing, toileting, bathing, self-feeding, brushing teeth, playing Yes No Comments Mobilitysitting, crawling, walking, running, kneeling, navigating obstacles Yes No Comments Neurologic/Seizures Yes No Comments Emotional/Psychological Yes No Comments Family EnvironmentMembers of the household(i.e. lives with both parents, grandparents etc) How many siblings to this child and placement in sibling order: Does your child get along well with other siblings? Favorite toys/activities: Daycare/PreschoolList any programs attended: Other Therapies and Support ServicesPhysical Therapy Yes No Comments Occupational Therapy Yes No Comments Speech Therapy Yes No Comments Applied Behavior Analysis (ABA) Yes No Comments Financial Agreement & InformationSelf-pay rates may vary by location and type of service. Please, inquire on our website or via email for our current rates. Payment is due at time of service. A therapy superbill will be provided with all necessary information for you to submit to your insurance plan for reimbursement according to your plan benefit. Non-refundable registration fees are charged monthly to help cover the cost of reserving the time slot, facility fees and administrative costs associated with running off-site programs. Registration fees do not cover therapy sessions themselves and client will be responsible for the fee for service per treatment rendered. Payment in full is required at the time of services being rendered. Registration fees must be paid upon reserving your appointments. Flourishing Littles reserves the right to amend its fee structure at any time.Current Insurance Plan: Policy Holder Name Policy Holder DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Financial Policy Acknowledgement(Required) (Medicaid recipients only) I authorize Flourishing Littles/Katelyn Roe to bill therapy visits to my Medicaid plan. (Commercial insurance holders/private pay clients) I agree to pay out of pocket fees for services rendered and understand that fees are due at the time of service provided. Flourishing Littles accepts credit card, Venmo, Zelle, and PayPal. I agree to update URS with current payment information. I certify that any service rendered by Flourishing Littles for the above will be paid by me, the Responsible Party. I understand that all services rendered by Flourishing Littles must be paid within 15 days of invoice date to prevent interruption of services and to avoid additional charges. By typing my name below, I am electronically signing this document. I understand that this electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. Attendance Policy We understand that illness and family emergencies do arise and ask that prompt notification be given if the appointment needs to be cancelled or rescheduled. Regular attendance to therapy visits is crucial to getting the best results for your child. For non-emergent cancellations, notice is required at least 24 hours in advance of the scheduled appointment by notifying via email, call, or text message in order to avoid a cancellation fee. Less than 24 hour notice or a no show will result in a $75 cancellation fee. If Flourishing Littles cancels appointments for any reason, every effort will be made to reschedule and no fee will apply. Specialty Services Policy Hippotherapy, Equine assisted therapy, home visits, group therapies, and workshops are offered to each individual client solely at the treating therapist’s discretion based on what is most therapeutic and beneficial to the client at time of treatment. To have the services available, you must be an established and current client of Flourishing Littles and your account must be in good standing. Flourishing Littles requires an established plan of care and does not provide a la carte services. Consent to Treat and Liability Waiver I authorize Flourishing Littles aka Katelyn Roe, MS, OTR/L, HPCS to provide occupational therapy treatment as deemed necessary. Client and Responsible Party represent that client has no condition that would indicate therapy is contraindicated or inappropriate at this time. This representation is made knowing that Flourishing Littles/Katelyn Roe will rely upon same representation for all therapeutic activities offered. I certify I will disclose any information related to change in status and will keep medical information on file current. Clients and guests using any facilities and equipment associated with Flourishing Littles do so at their own risk. Flourishing Littles shall not be liable for any damages arising from personal injuries or damages sustained in, on or about any operating location. Client and Responsible Party assume full responsibility for any injuries or damages and do hereby and forever release and discharge Flourishing Littles/Katelyn Roe from any and all claims, demands, damages, rights or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of the client’s, family’s or guests’ use of intended use of the facilities and/or equipment.By typing my name below, I am electronically signing this document. I understand that this electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature.(Required) HIPAA Compliance, Authorization, and Confidentiality Policy Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. A copy of the full disclosure can be found on our website. I authorize the following persons to have access to my record and/or to contact Katelyn Roe/Flourishing Littles on my behalf:Disclosure Contact Name Relationship Contact Information Disclosure Contact Name Relationship Contact Information Disclosure Contact Name Relationship Contact Information Emergency Contact and Authorization for EMT Flourishing Littles shall only disclose information to outside agencies/individuals with the specific written consent of the client/legal representative. In cases of medical emergency due to illness or injury while receiving services rendered by Katelyn Roe/Flourishing Littles or while receiving off-site services, this policy shall recognize the required Authorization for Emergency Medical Treatment as such required written consent. Flourishing Littles requires separate written consent for outside informants (Please use Authorization for Release of information form). In case of emergency, Flourishing Littles policy is to call 911 and to initiate CPR until EMS arrives.In the event of an emergency where the guarantor is not present/able contact:(Required) Name Relationship Phone Number Thank you for taking the time to complete this intake questionnaire. This will help streamline your initial evaluation visit for occupational therapy (OT) and allow me to jump right in to the assessment and clinical observation portions of this process. If you have had any assessments or services related to OT in the past, it may be helpful to share these reports with me. You can forward any supporting documentation along with this intake and any questions prior to your appointment.Hiddenhidden form field, do not fill