Authorization for Release of IEP from School System

    Patient's Name:

    Date of Birth:

    Name of School Child Attends:

    School System Child Attends:

    I hereby give my consent to to release current IEP to Southern Therapy Solutions.

    My child receives therapy in this school system. Information is needed regarding school related therapy for current school year to .

    Child Case History

    Child's Name:

    Date of Birth:

    Phone:

    Address:

    City:

    State:

    Zip:

    Did the child live with the birth parents?

    Reason for Referral

    Siblings (names and ages)

    Primary Language of the Child

    Any other languages spoken in the home (please list)?

    Does the child present a speech-language, nutritional, fine motor, feeding, swallowing, weight, sensory, or hearing concern (please explain)?

    Does anyone in the family have similar concerns (please explain)?

    Is your child currently receiving any other therapy in the community (what type and where)?

    How does the child usually communicate (gestures, single words, short phrases, sentences)?

    When was the problem(s) first noticed (by whom)?

    Is the child aware of the problem(s)? If so, how do they feel about it?

    Prenatal and Birth History

    Mother's general health during pregnancy (illnesses, accidents, medications, etc.)

    Length of Pregnancy:

    General Condition:

    Length of Labor:

    Birth Weight:

    Medical History

    If applicable, please provide the approximate ages at which the child had the following illnesses/conditions.

    Asthma:

    Croup:

    Ear Infection:

    Headaches:

    Mastoiditis:

    Measles:

    Pneumonia:

    Tinnitus:

    Colds:

    Draining Ears:

    Has the child had any surgeries or diagnostic tests? If so, what type and when?

    Describe any major accidents or hospitalizations.

    Is the child taking any medications? If so, please identify.

    Developmental History

    If applicable, please provide the approximate ages at which the child began the following activities.

    Crawl:

    Sit:

    Stand:

    Walk:

    Feed Self:

    Dress Self:

    Use Toilet:

    Use Single Words:

    Combine Words:

    Name Simple Objects:

    Ask Simple Questions:

    Engage in Conversations:

    How does the child interact with others (shy, aggressive, etc.)?

    Family History
    If applicable, please list any family members with the following diagnoses.

    Autism:

    ADHD:

    Bi-Polar Disorder:

    Depression:

    Schizophrenia:

    Anxiety:

    OCD:

    ODD:

    Other:

    Has the patient experienced recent physical/emotional trauma or major life changes (divorce, deaths, moving, etc.). If so, please explain.

    Patient's Strengths and Weaknesses

    Patient preferences and familiar things

    Top 3 goals/areas you would like to see change or improve for your child over the next 6 months

    Person Completing Form:

    Relationship to Child:

    Diaper/Bathroom Assistance Authorization

    Patient Name:

    Patient DOB:

    I authorize the Southern Therapy Solutions staff to:

    If you authorize us to apply topical ointment, in which scenarios:

    Allergies to latex?

    Diaper/Pull-Up brand provided:
    Ointment brand provided:
    Further Instructions:

    I do authorize Southern Therapy Solutions staff to change my child's diaper/take them to the bathroom, while in the clinic receiving treatment. I agree to supply an extra change of clothes, wipes, diapers, ointments, and any other supplies needed. I understand it's my responsibility to make STS staff aware of any allergies or sensitivities related to diapers, ointments, or anything else of that nature. Southern Therapy Solutions staff will contact the parent/guardian if the child is out of diapers. Staff will use gloves during the diaper changing process.

    -- or --

    I do NOT authorize Southern Therapy Solutions staff to change my child’s diaper/take them to the bathroom.

    Please select one

    Medication Log

    Child's Name:

    Date:

    I give permission for STS to administer the following medication to my child. I will not hold STS liable in the event of reactions or complications arising from my child receiving this medication. All medication needs to come in a labelled container from the pharmacy. Any over the counter medication needs to be in a new, unopened container.

    Name of medication:

    Reason for medication:

    Start Date:

    Finish Date:

    Times for each dose:

    Amount per dose:

    Illness and Sick Policy

    To maintain a safe and healthy environment for all patients, families, and staff, we ask for your cooperation with the following illness policy. There may be occasions when a patient or staff member becomes ill during the day. If a patient becomes sick while in our care, we will contact you immediately so that arrangements can be made for the patient to be picked up as soon as possible.

    A patient or staff member will be sent home if any of the following symptoms are observed:

    1. Fever of 100°F or higher
    2. Unexplained rash
    3. Vomiting
    4. Diarrhea
    5. Symptoms of COVID-19, influenza, or a severe cold, including but not limited to:
    ◦ Persistent cough
    ◦ Earache
    ◦ Eye infections
    ◦ Thick nasal discharge
    ◦ Fatigue
    ◦ Body aches
    ◦ Headache
    ◦ Sore throat
    6. Conjunctivitis (Pink Eye)
    7. Head lice
    8. Hand, Foot, and Mouth Disease

    Attendance Requirement

    Patients and staff members must not come to the clinic if they have experienced any of the symptoms listed above within 24 hours prior to their scheduled appointment or work shift. If a patient begins experiencing symptoms, please notify the treating therapist as soon as possible so that sessions may be canceled promptly.

    Return to Therapy
    A patient may return to therapy and a staff member may return to work only after being completely symptom-free for at least 24 hours, without the use of medication to reduce or mask symptoms.

    Please sign below to acknowledge that you have read, understand, and agree to comply with this policy. We appreciate your cooperation as we remain committed to providing the highest level of care in a safe and healthy environment.

    Patient Name:

    Date of Birth:

    Authorization for Release of Medical Information

    Effective Date:

    I hereby give my consent to to release Protected Health Information to Southern Therapy Solutions.

    Information is needed regarding medical care received from to for care received regarding .

    Consent Form

    Notice of Privacy Practices

    By signing this form, you acknowledge receipt of the Notice of Privacy Practices from Southern Therapy Solutions. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, you may obtain a revised copy by contacting our office staff. I hereby consent to and acknowledge receipt of Southern Therapy Solutions Notice of Privacy Practices. I consent that my protected health information be used to provide and coordinate treatment, to obtain payment, and for business operations. I understand that Southern Therapy Solutions Notice of Privacy Practices explains my rights to privacy regarding my protected health information and provides specific information and a complete description of how my health information may be used and disclosed. I acknowledge receipt of the Notice of Privacy Practices from Southern Therapy Solutions.


    Consent to Text
    Consent to Text indicates whether the patient has agreed to receive automated text alerts from Southern Therapy Solutions on their mobile phone. Depending on the features the practice offers, text alerts may be about appointments, test results and more. Please select “I Accept” if the patient agrees to receive automated text alerts. Select “I Decline” if the patient declines.

    Credit Card Authorization

    Sign and complete this form to authorize Southern Therapy Solutions to make a monthly charge to the credit card listed below. The card will run on the last business day of each month. By signing this form, you give us permission to debit your account for the amount indicated on your monthly statement. This permission for a once monthly transaction and does not provide authorization for any additional unrelated debits or credits to your account.

    I , the parent or guardian of , authorize Southern Therapy Solutions to charge my credit card account indicated on my monthly statement. This payment is for Speech, ABA, Occupational Therapy or Dietary Services at Southern Therapy Solutions.

    Patient Information

    Patient Name:

    Preferred Name:

    Date of Birth:

    Sex:

    Cell Phone:

    Work Phone:

    Address:

    City:

    State:

    ZIP:

    Driver's License Number:

    Appointment Availability (days):

    Appointment Availability (time):

    Father's Name:

    Father's DOB:

    Home Phone:

    Cell Phone:

    Work Phone:

    Mother's Name:

    Mother's DOB:

    Home Phone:

    Cell Phone:

    Work Phone:

    Emergency Contact:

    Emergency Contact Phone:

    Best time to contact me:

    Best way to reach me:

    Choose appropriate option for patient:

    If student,

    Name of School:

    City/State:

    Does the child receive therapy services in the school system?

    Has the child received therapy services at another clinic?

    Primary Physician Name:

    Primary Physician Number:

    Referring Physician Name:

    Referring Physician Number:

    Insurance Information

    Relationship to Patient

    Name:

    Phone:

    Address:

    City:

    State:

    ZIP:

    Email Address:

    Social Security Number:

    Employer:

    Primary Insurance

    Name of Policy Holder:

    DOB:

    Name of Employer:

    Work Phone:

    Insurance Company:

    ID Number:

    Group Number:

    Insurance Company Address:

    City:

    State:

    ZIP:

    Insurance Company Phone:

    If you have any additional insurance, please complete the following secondary insurance information.

    Secondary Insurance

    Name of Policy Holder:

    DOB:

    Name of Employer:

    Work Phone:

    Insurance Company:

    ID Number:

    Group Number:

    Insurance Company Address:

    City:

    State:

    ZIP:

    Insurance Company Phone:

    I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. If for any reason any portion is not paid for by my insurance, I agree to make arrangements for prompt payments of the account. I have read all the above information and completed the above answers truthfully and correctly. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status regarding the above information.

    Date:

    Document(s):