Community Autism Center: West ChesterWelcome Packet "*" indicates required fields Step 1 of 5 20% Parent or Guardian First Name*Parent or Guardian Last Name*Phone Number*Email Address* Client HistoryGeneral InformationChild's Full Name*Date of Birth* MM slash DD slash YYYY Street Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code*Is this address the same as your billing address? Yes No If not, please provide your billing address.Please list anyone else who lives in the home with you, their relationship to the child, and their phone number and email address.If applicable, do you have full custody of the child? Yes No *If no, please provide a copy of the custody agreement. If partial or joint custody, both parties will need to consent to treatment.Languages spoken in the home:How did you hear about EBS Children's Therapy? Emergency Contact Information Emergency Contact Name 1:Relationship to PatientPhone Number Emergency Contact Name 2:Relationship to PatientPhone Number Present Medical Information Describe present concern related to appointment.Have any previous therapies or approaches been attempted? Yes No If yes, please describe.Have there been any significant medical or behavioral changes in the past 6 months? Yes No If yes, what has changed?Does your child have allergies? Yes No Please list all allergies.What is your child's current health? Good Fair Poor Is your child taking any medications? Yes No Please list medications.Does your child have any other medical diagnoses or concerns?Does your child have any adaptive or medical equipment? Yes No Please list adaptive or medical equipment.Describe any illnesses, accidents, hospitalizations (include age/treatment).Does your child have problems hearing? Yes No Please explain hearing problem(s).Has your child experienced any ear Infections? Yes No Approximately how often? Rarely Occasionally Often Has your child had middle ear tubes inserted? Yes No When were the ear tubes inserted?Has your child's hearing ever been tested? Yes No Results of hearing test:Did your child have his/her adenoids or tonsils removed? Yes No If yes, when?Does your child snore? Yes No Does your child wear corrective lenses (glasses, contacts)? Yes No At what age did your child begin to wear them? Therapy Goals Please describe your goals for therapy. What do you hope to accomplish?Are you in need of any additional supports besides what you are being seen for today? Yes No If yes, please describe. Birth History Was pregnancy full term? Yes No Was there anything remarkable about the mother's health during pregnancy or delivery? Yes No If yes, please explain.Type of Delivery: Vaginal Caesarian Breech Suction Forceps Was there any type of diagnosis or medical concern about the baby after birth? Yes No If yes, please explain.Please describe any family history of developmental or learning problems. Education/Therapy Information Is your child enrolled in any type of childcare facility, preschool program, play group, developmental program, public school, or private school? Yes No Name of school/facility:How long has your child attended?Hours enrolled per week:Current grade level:Has your child ever had a school-based evaluation? Yes No Please briefly describe the results.Does your child have an IEP? Yes No What type of services do they receive? *Please provide a copy of the IEP and Evaluation to EBS Children’s Therapy. Has your child had an evaluation (speech therapy, physical therapy, occupational therapy, behavior analysis) in the past 6 months? Yes No Does your child currently receive services for any of the following services? This field is hidden when viewing the formABA Yes No Speech (ST) Yes No Occupational Therapy (OT) Yes No Physical Therapy (PT) Yes No Counseling/Psychological Yes No If yes, where are you receiving these services, and will you continue to receive these services while at EBS Children’s Institute? In the event you plan to receive therapy services from two locations, please be aware you may be responsible for costs not covered under your insurance policy. Informed ConsentChild's NameDate MM slash DD slash YYYY CONSENT FOR THERAPEUTIC TREATMENT I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at EBS Children’s Therapy. I understand that I may terminate these services at any time. * I consent to the above. CONSENT FOR PARTICIPATION WITH THERAPEUTIC EQUIPMENT Intervention programs at EBS Children’s Therapy usually involve the use of specialized equipment such as various swings, bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh and lotion), and a variety of other activities that involve fine, gross, and oral motor coordination. Therapy activities often involve encouraging the child to try new things in order to foster increased skills and abilities. While EBS staff make great efforts to ensure each child’s safety, the nature of the therapeutic intervention includes the risk of falling and bumping into other people/equipment. I am aware of the inherent risk of this type of activity, and I give permission for my child to participate in therapy as described. * I consent to the above. REVIEW OF RECORDS/RELEASE OF INFORMATION I consent to communication between EBS Children’s Therapy and other therapists, teachers, and/or doctors that have previously worked and/or are currently working with my child. I understand that information may be shared with another member of my child’s treatment team outside of EBS, as well as shared with professionals within EBS as part of the treatment process. I understand that the information that is released between the treatment providers is confidential and is for the well-being of my child. * I consent to the above. CONSENT FOR VIDEOTAPING & PHOTOGRAPHING FOR THERAPEUTIC PURPOSES Therapists often videotape or photograph children who receive therapy services at EBS to help monitor and document a child’s areas of concern, as well as progress. Videotapes and photos are used and reviewed only by EBS staff. Parents are welcome to view their child’s videotape at EBS.I _______ give consent for my child to be videotaped and/or photographed as part of his/her therapy program for use by EBS Children's Therapy staff only.* Do Do Not CONSENT FOR VIDEOTAPING & PHOTOGRAPHING FOR EDUCATIONAL & PUBLIC AWARENESS PURPOSES Staff at EBS are frequently asked to teach at courses, seminars, or workshops. We often like to Include videotape, slides, or photos during our presentations. Additionally, we may occasionally use photographs to share on Social Media and for promotional purposes. I _______ give permission for my child to be videotaped/photographed for educational and public relations purposes. I understand that my child's name and any identifying information will not be used in association with these images.* Do Do Not EBS Children's Therapy Health PolicyFor the safety of your child, parents/guardians of children with Allergies, Asthma, or Seizures you must remain present either in the therapy room or the waiting area during the entire therapy session. If a seizure, asthma attack, or allergic reaction occurs during a therapy session, the therapist will need to end the session. Allergy Does your child have allergies?* Yes No Allergic to:Please describe reaction.Medications given: If you checked yes, please fill out the Allergy Plan at the end of this section. If you do not feel a plan is necessary at this time, please check the box below. I do not feel my child needs an allergy plan at this time. Seizure Does your child have seizures?* Yes No Frequency:Please describe seizures.Medications given: If you circled yes, please fill out the Seizure Plan at the end of this section. If you do not feel a plan is necessary at this time, please check the box below. I do not feel my child needs a seizure plan at this time. Asthma Does your child have asthma?* Yes No Known triggers:Frequency of attacks:Medications given: If you circled yes, please fill out the Asthma Plan at the end of this section. If you do not feel a plan is necessary at this time, please check the box below. I do not feel my child needs an asthma plan at this time. Allergy Plan Please list allergens and reactions.Click the plus sign (+) on the right to add rows.AllergenReaction Add RemoveDate of Plan MM slash DD slash YYYY Child's NameDate of Birth MM slash DD slash YYYY Parent/Guardian NamePhone NumberAlternate Phone NumberPhysician NamePhysician Phone Number Emergency Contact NameEmergency Contact Phone NumberAlternate Phone Number Brief description of child's allergies and reactions:Click the plus sign (+) on the right to add rows. Click the plus sign (+) on the right to add rows.If child displays the following symptom:Take the following action: Add Remove EBS Children’s Therapy Staff will do its part to be continually aware of the child’s specific allergy. However, it is not possible to prevent 100% of all accidental exposures in a center which is frequented by such a large group of clients and families each week. By signing at the end of the Welcome Packet, you understand that EBS Children’s Therapy will not be held liable for any reactions that a child has to contact with our clinic environment. Before serving your child, EBS will need a copy of your child’s emergency allergy plan. If the emergency plan requires medication (EpiPen, inhaler, etc.), we require parents to stay on the premises for the duration of the session. Seizure Plan Known triggers for seizues:Date of Plan MM slash DD slash YYYY Child's NameDate of Birth MM slash DD slash YYYY Parent/Guardian NamePhone NumberAlternate Phone NumberPhysician NamePhysician Phone Number Emergency Contact NameEmergency Contact Phone NumberAlternate Phone Number Brief description of your child's seizures:Click the plus sign (+) on the right to add rows. Click the plus sign (+) on the right to add rows.If child displays the following symptom:Take the following action: Add Remove EBS Children’s Therapy Staff will do its part to be continually aware of the child’s seizure history, avoid known seizure triggers, and monitor at all times for signs and symptoms. As it is not our policy to administer medications, a parent or caregiver must remain present either in the therapy room or the waiting area during the entire therapy session in case such an event may occur. In the event of a seizure, EBS Children’s Therapy Staff will work with the family to safely position the child until which time the child is okay or emergency medical service arrives. The therapy session will end if a seizure occurs. By signing at the end of the Welcome Packet, you understand that EBS Children’s Therapy will not be held liable for any seizure that a child may have in our clinic environment. Asthma Plan Known triggers for asthma:Date of Plan MM slash DD slash YYYY Child's NameDate of Birth MM slash DD slash YYYY Parent/Guardian NamePhone NumberAlternate Phone NumberPhysician NamePhysician Phone Number Emergency Contact NameEmergency Contact Phone NumberAlternate Phone Number Brief description of your child's asthma and reactions:Click the plus sign (+) on the right to add rows. Click the plus sign (+) on the right to add rows.If child displays the following symptom:Take the following action: Add Remove EBS Children’s Therapy Staff will do its part to be continually aware of your child’s asthma history, avoid known triggers, and monitor at all times for signs and symptoms. As it not our policy to administer medications, a parent or caregiver must remain present either in the therapy room or the waiting area during the entire therapy session in case such an event may occur. In the event of an asthma attack, EBS Children’s Therapy Staff will work with the family to safely maintain the child until which time the child is okay or emergency medical service arrives. The therapy session will end if an asthma attack occurs. By signing at the end of the Welcome Packet, you understand that EBS Children’s Therapy will not be held liable for any asthma attacks that a child may have in our clinic environment. Custodial/Court Documentation AcknowledgementPlease check one of the following statements. I, the parent/guardian, do hereby acknowledge that there is NO custodial/court documentation in place for the child(ren) listed below as of today’s date. Parent/Guardian NameDate MM slash DD slash YYYY Child(ren)'s Name(s): OR I, the parent/guardian, do hereby acknowledge that there IS custodial/court documentation in place for the child(ren) listed below as of today’s date. In addition, I will provide a copy of the custodial/court documentation to EBS Children’s Therapy. Parent/Guardian NameDate MM slash DD slash YYYY Child(ren)'s Name(s): Financial Policy 2020As a courtesy to all of our patients, we will call to verify benefits and will make reasonable effort to collect from your insurance company, should you choose to utilize insurance. Please understand, however, primary responsibility for understanding coverage limits belongs to the parent. There are instances when insurance may deny benefits (deductible not met, services not covered under the plan, etc.) and you will then be responsible for payment. In the event that insurance denies payment, the family may wish to appeal the matter to their insurance company, and we will support the parent in their effort. Any payment which is deemed to be due from the parent (private pay/co-pays) is due at the time of the service. If a payment plan is required, those terms will be provided to you in writing and agreed upon by both EBS Children’s Therapy and the person responsible for patient’s bills. Please inquire with our office administration regarding rates for services. Notification of Insurance Changes/Renewal Policy EBS Children’s Therapy (EBS) must have current information on file regarding Insurance at all times. It is the responsibility of the parent/guardian to know of any and all changes that may occur in your insurance policy. It is also the responsibility of the parent/guardian to be sure that EBS is aware of any and all changes to the policy at or before the time that they go into effect. Please note that many insurance policies change on January each year, however they can change at any time. IMPORTANT: *Notification of Change: All changes must be directed to the Clinic Administration Staff and appropriate insurance card and identification provided. All co-pays must be PAID AT TIME OF SERVICE. We can offer to have a credit card on file for your co-pays if you prefer. We thank you in advance for your cooperation and invite you to call the Clinical at 610-455-4040 with any questions that you may have about billing. I have read and agree to my financial responsibility for the services provided to me by EBS Children’s Therapy. This also certifies that the information I have provided to EBS Children’s Therapy, to the best of my knowledge, is true and accurate. I authorize my insurance carrier to pay EBS Children’s Therapy the full and entire amount of the bill incurred by my child. Child's NameDate MM slash DD slash YYYY