Welcome to SmallTalk - we're glad you're here!
We are excited to be working with and learning more about you and your family. There are a few things we'd like you to know about us, too.
1. Locations
We currently have three locations:
· East County: Our EC clinic is our largest clinic with three speech-language treatment rooms and two occupational therapy rooms.
· North County: Our NC clinic includes two speech-language treatment rooms and one occupational therapy gym.
· Old Town: Our OT clinic is our newest clinic and includes two speech-language treatment rooms and one occupational therapy gym.
· We also provide services at several local preschools and childcare centers. Let us know where your child spends their day and we can tell you if we offer treatment on site.
2.The SmallTalk Team
We have a dynamicteam of clinicianswho loveworking with childrenwith a broad range of diagnoses, abilities and developmental levels. Our clinicians truly are a collaborativeteam, and we're happy to bring you on board as the newest member of that team! Together, we will strive to ensure all of your child's needs are met in a holistic, child and family-centered way.
At SmallTalk, it is not uncommon for a speech-language clinician to invite an occupational therapist intoa session to provide information about a child's fine motor or sensory needs, for an occupational therapist to consult with a speech-language clinician about what speech-language targets she can include in the child's session, or for all team members to collaborate and think of ways to best meet a child's needs.Because weunderstand the importance of treating the whole child, wemay ask about your child's school placement and performance, andother therapies and services they receive.
3. Other Details
· Homework: Because we believe in family centered therapy and because we want your child to carry their newskills over to home and school, we often implement homework programs. Please bring your child's homework folder back and forth each week so we can review last week's lesson and prepare a new, appropriate assignment.
· Financial Information: Please make necessary payments and co-paymentseach visit. These can be given to Shauna, SmallTalk's office manager, or directly to your clinician.
· Privacy: At SmallTalk, we are committed to protecting your confidentiality. For this reason, please go into your child's treatment room for feedback and discussion about the day's visit. For 30-minute sessions, please enter the room 25 minutes after the scheduled start time and for 60-minute sessions, please enter the room 50 minutes after the scheduled start time.
· Cancellations: Consistent attendance and practice is crucial for a successful therapy program. Therefore,cancellations made less than 24 hours before a scheduled treatment session will result in a $30 fee if they cannot be re-scheduled that week.
Again, we're happy to have you on our team and look forward to working with you! Please let us know if you have any questions or if there is anything you need.
Sincerely,
The SmallTalk Team
Policies and Procedures
Please initial each box
Payments:
Therapy fees (including co-pays) are due at time of service. Payments can be given to your therapist or mailed in. Please make checks payable to SmallTalk Speech Therapy.
You are responsible for all costs/ fees that your insurance company does not cover
SmallTalk bills health insurance companies as a service to our clients, including submissions of claims and appeals. However, in the event that your insurance provider or health plan determines our services to be “not covered”, you will be responsible for all outstanding charges. All payments are due upon receipt of a statement from SmallTalk.
A 1.5 % interest charge will be added to 30-days past due accounts. Accounts over 90 days past due will be turned over to a reputable collections agency. If you terminate therapy for any reason, you will be responsible to pay all fees, co-pays, coinsurance and deductibles immediately.
Out-of-Pocket Payment: For those paying out of pocket, we have a day-of-service discount for speech therapy session. When you pay on the day of service, our rates are: $60 for a 30-minute session and $110 for a 60-minute session.
Cancellations: Our therapists prepare ahead of time specifically for your child’s session.
It is our policy to charge $30 to clients who do not provide 24 hours notice for cancellations. We do realize that children wake up sick from time to time. In this event, parents should call their therapist on or before 8:00 am the day of your child’s appointment. If the call is received later than 8:00 am you will be responsible to pay a cancellation fee of $30.
Medical insurance does not cover cancelled or missed appointments. In emergency situations (earthquake, motor vehicle accident, etc.) we do not require any notice and will not bill the client for the cancelled appointment. Three un-cancelled “no shows” are grounds for termination of treatment.
That being said, if your child is sick, please keep him/her home. Children who are not feeling well will not do well in therapy. If the child is not contagious and is in good spirits, you can bring them to therapy!
Observation:
During therapy, parents are welcome to observe therapy, wait in the waiting room or run errands.
Please be on time to pick up your child.
Your child’s session ends five minutes before the allotted time (25 minutes if a 30-minute session, 55 minutes if a 60-minute session) to allow you time to catch up on their progress and be updated on their homework. The next client will be taken at their scheduled time and no one will be available to supervise your child.
Siblings should not be left unattended while parents are observing therapy. It is our preference that siblings do not accompany parents during observation as it may be distracting to our clients. If siblings are present it is preferable that they wait in the waiting room during therapy with parent supervision.
New Patient Registration
Patient First and Last Name
Female____ Male____ Birthdate______Today’s date______Any known Allergies?
Parent or Guardian
Address
City, State, Zip Code
Home Phone ______Cell ______Work
Email address
What is the best way to contact you for scheduling? ___ Email ___ Phone
If you have a balance due, how would you like to be billed? ___ Email (preferred) ___ Mail
How did you hear about SmallTalk?
Insurance Information
Insured First and Last Name
Billing Address (if different from above)
Employer
Insurance ______Insurance Phone
Insurance Address
Insurance City, State, Zip Code
Social Security or Policy Number
Group Number
Medical Information
Referring Physician
Physician’s Phone
Physician Address
Diagnosis______Diagnosis Code
Assignment and Release
I understand that I am financially responsible for payment to SmallTalk Speech Therapy for charges not covered by my insurance company. I authorize medical benefits to be paid directly to SmallTalk Speech Therapy. I also authorize SmallTalk Speech Therapy or the insurance company to release any information required for this claim. I understand that any unpaid balance over 60 days is subject to being turned over to a collections agency and/or a 1.5% monthly finance charge on the unpaid balance.
______
Parent / Legal Guardian Date
Authorization for Release of Protected Health Information
Child’s name:
Address:
City, State, Zip Code:
Birth Date:
I hereby authorize SmallTalk Speech and Occupational Therapy, Inc. to release pertinent health information regarding my child to the following facilities. This includes medical records, clinic notes, school records and any pertinent information that will help in developing my child’s treatment program.
Facility:
Address:
City, State, Zip Code:
Phone:
Facility:
Address:
City, State, Zip Code:
Phone:
I understand that by signing this authorization:
· I authorize the use or disclosure of my individually identifiable health information as described above for the development of my child’s treatment program.
· I have the right to withdraw permission for the release of my child’s information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
· I have the right to receive a copy of this authorization.
· I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.
· I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
Parent/ Guardian:
Address:
City, State, Zip Code:
Phone:
______
Parent / Legal Guardian Date
Important Financial Information
It is critical that you be familiar with your insurance coverage for speech therapy. In order to provide uninterrupted treatment, it is necessary to be aware of what insurance requirements apply to your plan.
It is strongly recommended that you, the parent or guardian, contact your insurance company to see what therapy benefits apply to your plan. If a physician’s referral for speech therapy is required by your insurance plan, you are responsible to request and provide the referral. Insurance plans often require pre-authorization for speech therapy, and occasionally there is a limit on the number of visits allowed or an annual monetary cap. SmallTalk Speech Therapy will make every effort to keep you informed of the status of your insurance benefits. However, the final responsibility rests with you, the parent or guardian.
· We will bill your primary insurance.
· If you are paying out of pocket for your services, we will furnish you with a receipt as often as you request, as well as other paperwork necessary for your own records, taxes or flexible spending account reimbursement.
· Payments (including co-pays) are due at the time of service.
· In the event that your health plan determines any service to be “not covered”, you will be responsible for all outstanding charges. All payments are due upon receipt of a statement from SmallTalk. A 1.5% interest charge will be added to 60 days past due accounts, and may be turned over to a collections agency. If you terminate therapy for any reason, you will be responsible to pay all fees, co-pays, co-insurance and deductibles immediately.
· Please notify your therapist 24 hours in advance if you must cancel.
· If notification is not received by 8:00 AM the day of your child’s appointment, a $30 “no-show” fee will be charged directly to you.
· If you change insurance plans or companies, please let me know as soon as possible to expedite correct billing.
I understand that I am financially responsible to SmallTalk Speech Therapy for charges not covered by my insurance company. I also authorize SmallTalk Speech Therapy to release any information to my insurance company that is required for processing of this claim. I hereby authorize speech therapy as prescribed by my physician.
______
Signature of Parent / Legal Guardian Date
Authorization for Emergency Care
Child’s birthdate:
Allergies:
Medicine child is allergic to:
What medication is the child currently taking?
Pertinent medical history that would affect emergency care:
Parent Name:
Phone Number: (home)______(work or cell)
Emergency Contact:______Relationship to child:
Emergency Contact Phone Number:
I, ______authorize SmallTalk Speech Therapy to call for appropriate emergency medical treatment for ______if necessary in my absence.
______
Signature of Parent / Legal Guardian Date
Speech Therapy Parent Report Form
Child’s name______M/F______Today’s date
Parent(s)______Child’s birthdate
Home Phone______Work or Cell Phone______Child’s age
Primary language spoken in the home?______Other languages?
Describe your concern with your child’s speech and/or language skills.
At what age did you first note the problem?
Does anyone else in your family have a speech problem? If so, whom?
Please describe:
Did your child babble? At what age?
At what age was your child’s first word?
What were your child’s first words?
Once your child started to use words, did the development of new words continue?
If under 4 years of age, how many words does your child use? (Circle one—you may include signs)
0-20 20-50 50-100 100-150 200-300 300-500 500 or more
If 0-20, please give examples______
Does your child produce phrases and sentences?
2-word 3-word 4-word 5-word more
Please give examples______
______
Does your child have difficulty making some consonant/speech sounds? If so, please list them:
If your child is not using words, how do they communicate with you?
______
Does your child play and communicate well with his friends and family?
How does your child relate to other children his/her age when playing?
How does your child transition from activity to activity (e.g. easy, with tantrums, needs prompts, etc.)?
______
Please rate your child’s eye contact skills (e.g. poor, fair, good).
Give an example of a direction or command that your child will typically follow.
In a percentage, rate how much of your child’s speech you understand.
How well do others outside the family understand your child when he speaks (in a percentage)?
How does your child’s speech difficulties impact your family life?
At what age did your child meet these developmental milestones?
Sitting______Walking______
Does your child have a history of:
Ear infections?______How often?______Were tubes placed?______When?
Allergies?______What kind?______How severe?
Asthma?______How severe?
Has your child ever had:
Surgery______If so, what type and date?
Chronic illness______If so, what type and date?
Serious accident______If so, what type and date?
Did you have a normal pregnancy and delivery?
What is your child’s current health?______
Is your child currently taking any medications?______If so, what?______
Are there or have there been any feeding or eating problems (for example, any problems with sucking, tolerating specific food textures, swallowing, drooling, chewing)? If yes, please describe
______
Has your child ever had a hearing evaluation?______Date
Results
Does your child have any other diagnoses (e.g. Autism, PDD-NOS, Down Syndrome, Fragile X, Sensory Integration Dysfunction, etc.)? ______