PARENTS’ CONFIDENTIAL REPORT All the following information is for the confidential use of Professional staff only. According to my records, you have requested an examination for your child. In preparation for this examination, I would like you to provide me with the requested information of this form. This information is very important and will assist me in planning for and conducting a meaningful examination. Please answer the questions as fully and accurately as possible. Many parents have found the child’s baby book helpful in remembering particular dates. If you are not sure of a particular date, please write the date that you think is right and put a question mark after it. Date:______________ Child’s name:_____________________________________Birthdate:_____________Sex:_________ (first) (last) Street Address:__________________________________________Telephone:____________________ City:_______________________State:______County_______________________Zip______________ Child’s Physician_____________________Complete address:___________________________________ Referred by:________________________________________________________________________ Presenting Concerns:__________________________________________________________________ Parents: Marital Status of Parents: Married______Separated______ Divorced______Widowed_____Single__________ FATHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age____________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ MOTHER’S NAME:_______________________(Natural/Adoptive)Birthdate:__________Age:___________ Occupation and place of employment:_______________________________________________________ Work phone:____________________Highest grade completed in school:____________________________ Describe in your own words your concerns :___________________________________________________

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2 When did you first become concerned?_________________________________________________________

What do you think caused, or is causing this? ___________________________________________________

Is there a language other than English spoken in the home? _____ If yes, which language? _________________

Does the child understand the language? _____ Which language does the child prefer to speak? ______________

Has your child ever undergone a speech/language evaluation/screening? _____

Has your child ever received speech/language therapy? _____

If yes, where and when? ___________________________________________________________________

What was your child working on? ____________________________________________________________

Has your child received any other evaluation/screening or therapy? (ie physical therapy, occupational therapy,

counseling, vision, etc.) _____ If yes, please describe: ____________________________________________

___________________________________________________________________________________

CHILDREN (use additional page if necessary) Name Sex Birthdate Age Special Problems ____________________ ________ ___________ ____ ______________________ ____________________ ________ ___________ ____ ______________________ ____________________ ________ ___________ ____ ______________________

BIRTH HISTORY:

Normal Pregnancy?______________ Complications during pregnancy?___________________________

Any special tests during pregnancy?_____________________________________________________

Diet or medications?_________________________________ Weight gained?____________________

How long was labor?______________________ Was your child pre-mature?________________________

Any difficulties during delivery?________________________________________________________

Delivery by C-Section or vaginal? _______________

Did baby have any special problems or birth defects?__________________________________________

Approximate birth weight:__________________ Length of baby:_______________________________

DEVELOPMENTAL HISTORY (Give the age when your child:)

Sat alone: ____________Walked alone:____________ Crawled on hands and knees: _________________

Said first word:___________ Fed self:__________

Said first sentences:_______________ Toliet trained for day:______________ Night:________________

Dressed self:_______________ Rode tricycle:_________________ Tied shoes:____________________

SCHOOL HISTORY (preschool, day care, etc.)

Name of present school:_________________________________________Grade:________________

Teacher:_____________________________ School Address:________________________________

School performance: Superior____ Average____ Poor____ What grade has he repeated?________________

Does your child have poor handwriting? __________ Does your child have poor attention overall? _________

Does you child have difficulty keeping up with notes/note taking at school? ___________________________

Is your child having difficulty with any particular subject? _______________________________________

___________________________________________________________________________________

What are your child’s strengths and/or best subjects? __________________________________________

___________________________________________________________________________________ Has your child ever had an IEP? __________ Where?____________________ When? ______________

3 BEHAVIORAL CHARACTERISTICS Please circle all traits which best characterize your child’s current behavioral characteristics: cooperative poor eye contact attentive easily distracted withdrawn separation difficulties destructive/aggressive inappropriate behavior easily frustrated/impulsive plays alone for reasonable

length of time hyperactive

MEDICAL HISTORY Has your child experienced any of the following? (Please circle all that apply and list child’s age at time) adenoidectomy encephalitis seizures allergies flu sinusitis chicken pox head injury sleeping difficulties frequent colds measles meningitis tonsillectomy mumps scarlet fever vision problems earaches or draining in ears hearing problems vomiting headaches serious high fevers diminished sleep Has your child had Convulsions, spasms or seizures?_____ How many?_____ When was the last?_______________

Clumsiness or weakness of arms or legs?________________________________________________________

Does your child wear glasses?______ Date of last eye exam? _________________________________________

Bedwetting?______ Excessive number of accidents?_______________________________________________

Has your child received medical attention for hearing problems? _____ When? ______________________

Describe:_____________________________________________________________________________

Doctor’s name and address:___________________________________________________________

Has your child had an EEG (brain wave test)? _____ When?_____________ Where?_______________________

Why?________________________________________Results:____________________________

What other serious illnesses, injuries, or surgeries has your child had and _________________________________

___________________________________________________________________________________

Please list any medications that your child takes regularly: ________________________________________

___________________________________________________________________________________

Please list any past medications and reason discontinued: ________________________________________

___________________________________________________________________________________

Does your child use right or left hand or both?_________________________________________________

Is your child in good health at this time?_____________________________________________________

Does your child have any physical limitations?_________________________________________________

How is the health of other family members?_____________________________________________________

SOCIAL HISTORY: Describe your child’s interests: (play activities)_______________________________________________

______________________________________________________________________________

Playmates :(age and sex)_____________________________________________________________

What things does your child fear?________________________________________________________

Is your child nervous?____________ How long does he/she show it?______________________________

Has your child been harder to manage or discipline than other children?_____________________________

Is your child constantly into everything?___________________________________________________

Describe any eating problems:_________________________________________________________

4 Describe any toileting problems:________________________________________________________

Does your child separate easily from parents?________________________________________________

Did your child enjoy cuddling?__________________________________________________________

SPEECH AND HEARING: During the first year, did he/she make much sound other than crying?______________________________

Other than crying, would you say he was: a silent baby____ a very quiet baby____ an average noisy baby_____

At what age did he/she first say words?_______ What were they?_________________________________

______________________________________________________________________________

At what age did he/she have a name for most common objects and familiar people?________________________

At what age did he/she combine words into small sentences like: “Want drink” or “Me out”?_______________

At what age did he/she use more complete short sentences?_____________________________________

Did speech learning ever seem to stop for a period of time?______________________________________

Does your child seem to be aware of his/her speech differences?___________________________________

Are there some words that your child appears to understand but cannot say?(e.g. bye-bye, baby, no, cookie, etc.)__

______________________________________________________________________________

What efforts have been made to help your child talk better?______________________________________

Has there been a change in your child’s speech or hearing?_______________________________________

Do you consider your child to understand directions and situations as well as other children their age? If not,

why?__________________________________________________________________________

Has your child received speech and/or hearing tests? When?_______________________________________

Where?____________________________Results:_______________________________________

Has your child received speech or hearing therapy?_____ When?_____________________________________

Where?_____________________________ How long?____________________________________

Does your child appear to respond to:

-His name_____ Soft noises_____ Loud noises_____ Vibrations____ Verbal instructions_____

-Verbal instructions with gestures_____ Gestures alone_____

How does your child make his needs known to you?___________________________________________

Has your child received services of any of the following: If yes, please give name, address and date seen. Also, please

contact those people/agencies below and have them send a copy of their findings to: Word of Mouth Speech & Learning

Associates, 217 Jamestown Park Road – Suite 9, Brentwood, TN 37027.

Psychologist:_____________________________________________________________________ Psychiatrist______________________________________________________________________ Pediatrician/Family Dr.:_____________________________________________________________ Otolaryngologist:__________________________________________________________________ Neurologist:_____________________________________________________________________ Other doctors:____________________________________________________________________ Speech Therapist:__________________________________________________________________ Speech and Hearing Center:___________________________________________________________

5 Physical Therapy: __________________________________________________________________ Occupational Therapy: ______________________________________________________________ Social Agency or Worker:____________________________________________________________ State or County Welfare Dept._________________________________________________________ Any testing by local school system:______________________________________________________ Guidance or Mental Health Center:______________________________________________________ County Health Dept.:_______________________________________________________________ Other agencies:___________________________________________________________________ Have you thought about or made application for other services at other agencies for your child?____________

When?_____________Where?______________________________________________________

ADDITIONAL COMMENTS AND OTHER IMPORTANT INFORMATION: If your child is adopted, please give any information you may have pertaining to natural parents:_______________

______________________________________________________________________________

Do you have any other comments to make that you believe would be helpful to me?_____________________

______________________________________________________________________________

Do you have any particular questions you would like to ask?_____________________________________

______________________________________________________________________________

Name of person who completed this form and relationship to child:________________________________

______________________________________________________________________________ Signature:_______________________________________________________________________ (Father) (Mother) (Guardian) (To be signed by both parents if living together)

__________________________________________________________________________________________

217 JAMESTOWN PARK ROAD – SUITES 9 & 10 * BRENTWOOD, TN 37027 * 615.376.3045 *

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____________________________________________________________________________________________ 217 JAMESTOWN PARK ROAD – SUITES 9 & 10 • BRENTWOOD, TN 37027 •615.376.3045•

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STUDENT INFORMATION

Date: ______________________

Name of Student: _______________________________________________ Age: ____ Date of Birth: _____________ School: __________________________ ________________________ School Phone: _________________ Grade: ____ Teacher(s):___________________________________________________________________________________________ Teacher(s) e-mail:______________________________________________________________________________________ Allergies: ____________________________________________________________________________________________ Pediatrician: __________________________________________________________________________________________

Mother: _____________________________________ Phone: (home) ________________ (cell)________________ Employer: ___________________________________ Phone: (work) ________________ Home Address: _____________________________ City: _______________ Zip : ______ Email Address: _______________________________________________________ Father: _____________________________________ Phone: (home) ________________ (cell)_______________ Employer: ____________________________________ Phone: (work) _______________ Home Address: _____________________________ City: _______________ Zip : _____ Email Address _______________________________________________________ Do you mind if your child’s session is briefly discussed with you in our lobby (with the therapist bringing you back to a therapy room for more sensitive discussions)? Check: Yes, I do mind _______ No, I do not mind ________ May Word of Mouth Speech & Learning Associates and Eppert OT display a picture of your child for use in Word of Mouth publications such as brochures or website? Check: Yes ________ No ________

____________________________________________________________________________________________

217 JAMESTOWN PARK ROAD – SUITES 9 & 10 * BRENTWOOD, TN 37027 * 615.376.3045 *

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PATIENT NOTIFICATION OF PRIVACY RIGHTS

The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the "medical records privacy law", HIPAA provides patient protections related to the electronic transmission of data ("the transaction rules"), the keeping and use of patient records ("privacy rules"), and storage and access to health care records ("the security rules"). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. This “Patient Notification of Privacy Rights” informs you of your rights related to disclosure of information. If you have questions about any of the matters discussed in this document, please ask your provider or Lynne F. Robertson, M.A., CCC – SLP (HIPAA contact for this office) for further clarification.

I, _________________________________, understand and have been provided a copy of Word of Mouth Speech & Learning Associates Patient Notification of Privacy Rights Document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form. Parent Signature: ___________________________________

Date: _____________________________________________

____________________________________________________________________________________________ 217 JAMESTOWN PARK ROAD – SUITES 9 & 10 * BRENTWOOD, TN 37027 * 615.376.3045 *

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AUTHORIZATION TO OBTAIN AND RELEASE INFORMATION

(Please fill out form in its entirety)

We the parents of ______________________________ do hereby give permission to:

(school) _______________________________________________________________________________

(physician) _____________________________________________________________________________

(other) ________________________________________________________________________________

(other) ________________________________________________________________________________

to furnish Word of Mouth Clinical Associates and/or Eppert OT with any information requested for the

assessment and or/treatment of our child.

We by this same instrument give our permission to Word of Mouth Clinical Associates and/or Eppert OT to

furnish:

(school) _______________________________________________________________________________

(physician) _____________________________________________________________________________

(other) ________________________________________________________________________________

an oral or written report of the testing, plan of treatment, and recommendations made for our child.

I understand that I may revoke this consent to release protected health information at any time, by written

request.

Parent Signature:___________________________________

Date: ____________________________________________

__________________________________________________________________________________

217 JAMESTOWN PARK ROAD – SUITES 9 & 10 • BRENTWOOD, TN 37027 • 615.376.3045 •

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What payment option do you prefer?

Pay by check/cash

Automatically run credit card on file

* There is a 2.4% processing fee on all credit or debit card transactions.

SERVICE AGREEMENT AND PAYMENT POLICY Revised 6/18/2019

Child’s Name: ___________________________________________ Phone: ___________________

Parent(s) Name: ______________________________________________________________

Address: ____________________________________ City: _______________ State: _____ Zip: _________

General Consent: I understand and consent to receive for my child the services of Word of Mouth Speech Clinical Associates. I do

hereby authorize the provision of evaluation and/or treatment services with the above named child and I agree to pay in full for

these services at the time of the evaluation and/or at the beginning of each month for therapy, in order to receive services. I

understand that I am subject to a late fee should I not pay for services by the due date posted on the invoice. I may request

additional documentation or services for my child, such as, progress reports; progress conferences; and school conferences which

will each incur a separate charge. By initialing, I am acknowledging that I have read and agree to the above. ______

For Children Receiving Therapy: I understand that my child’s on-site therapy services will be billed at $96 an hour and that I will

receive an emailed invoice. I understand that my child’s off-site therapy services will be billed with an additional travel fee.

Payment will be due at the beginning of the month, for the hours I have reserved for my child to receive treatment for the

upcoming month. I will be given an opportunity to submit in writing or via email any planned absences for that upcoming month so

that I will not be invoiced for those sessions. By initialing, I am acknowledging that I have read and agree to the above _______

Unplanned Absences: For any cancellations other than planned absences mentioned above, I understand that these missed

sessions will need to be made up. I understand that I have 30 days to make up every unplanned missed session during therapist

openings or Fridays. Some exceptions may be made for children seen off-site to be made up off-site. If I am not able to make up

the session within 30 days, cancel or don’t attend the scheduled make-up session, or decline to schedule a makeup session, I

understand that I will forfeit any additional make-up sessions for that particular missed session. I understand that Word of Mouth

has a make-up policy for cancellations and do not offer refunds or credits for missed sessions that are not made up in thirty days. I

understand that I will need to call or e-mail the office at least one hour prior to my child missing the session in order to avoid the

last-minute- cancellation fee ($25). By initialing, I am acknowledging that I have read and agree to the above. _______

Credit card information: Our office requires a credit card number to be securely kept on file. If payment has not been received by

the 31st

of the billed month, I understand that Word of Mouth will process my credit card for the amount past due. For your

convenience, there is a payment box located in the waiting area. Our office accepts cash, checks, Visa, MasterCard, and American

Express. *A 2.4% processing fee will be added to each credit card transaction.

Credit/Debit card# ________________________________________________

Exp. Date: ________________

Name on the Card: ________________________________________________

Address for Card: ________________________________________________

________________________________________________

My signature indicates that I have read and agree to the above policies and I assume responsibility for payment for my child’s

therapy services.

Parent Signature: _____________________________________________ Date: _________________

Office Representative: ________________________________________________ Date: __________________

217 JAMESTOWN PARK ROAD – SUITES 8, 9 & 10 • BRENTWOOD, TN 37027 • 615.376.3045 • contact@wordofmouthca.com