Case History – Birth To 3 Years

How did you hear about us?*
- Physician referral
- Word of mouth
- Facebook/instagram
- Google search
- Magazine advertisement
- Other
Name Of Physician
Name of Publication
Other Details
Clinic Location Child has appointment scheduled at*
- Pooler
- Richmond Hill
Child’s Name*
Birth Date*
Month
Day
Year
Preferred Name*
Sex*
- Male
- Female
Parent/Caregiver*
Email*
Phone Number*
Primary Language
Address*
Street Address Address Line 2 City State ZIP Code
Child lives with*
- Both Parents
- Mother
- Father
- Grandparents
My child is in the foster care system
- My child is in the foster care system
Are there any guardianship/custody issues our office should be aware of?*
- Yes
- No
Please briefly describe*
Primary Care Physician*
Medical Diagnosis*
Primary Concerns/Reason for Referral*
Has your child previously received therapy before? Select all that apply.
- ST
- OT
- PT
Where were services received and for how long?*
Why did your child discontinue receiving services?*
Emergency Contact(s)*
Phone*
Hospital Preference

In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.
Signature of Parent/Guardian*
Date*
Month
Day
Year
FAMILY
Names and ages of siblings
Name Age
Names and nicknames of family members close to your child: (ie: ‘nona’/grandmother)
Name Nickname
Names of pets
SCHEDULE
What time does your child nap?*

: Hours

Minutes

AM/PM
Does your child attend any regularly scheduled appointments or programs?
Name Day Time
PRE-NATAL & BIRTH HISTORY
Birth Type*
- Premature
- Full term
- Birth uneventful
- Birth eventful
How many weeks?*
Please describe*
Please describe any pre-natal issues
Was the child in the Newborn Intensive Care Unit?*
- Yes
- No
For how long?*
DEVELOPMENTAL MILESTONES
Sat at age
Walked at age
First words at age
Combined words at age
Please list any developmental milestones NOT met within appropriate timeframes
MEDICAL HISTORY
Please elaborate if any of the following are checked
- Hospitalizations
- Surgeries
- Medication
- Seizures
- Breathing Problems/Asthma
- Allergies
- Ear infections
- Frequent upper respiratory infections
- GERD
- Eats well
- Picky eater
- Nutrition a concern
- Bottle Feeding
- Sleeps well?
- Other
Please list all surgeries and dates*
Surgery Date
Please list all medications*
Name of Medication What addressing? Dosage Side Effects
Please list allergies*
Ear infections-How frequently?*
GERD- age diagnosed*
GERD- How treated?*
GERD- Have symptoms resolved?*
- Yes
- No
Current Weight?*
Current Height?*
Bottles fed per day*
Number of ounces*
Name of Formula*
Please describe your child’s health in general
HEARING
Has your child had any ear infections?*
- Yes
- No
Please list dates and treatment*
Date Where tested? Results
Has your child had PE tubes placed?*
- Yes
- No
Has your child been diagnosed with hearing loss?*
- Yes
- No
What type and severity?*
Does your child regularly wear aided hearing device?*
- Yes
- No
VISION
Has your child had his or her vision checked?*
- Yes
- No
What were results?*
Does your child wear corrective lenses?*
- Yes
- No
Does your child have a history of Estropia, Strabismus, Patching or Eye drop prescriptions?*
- Yes
- No
Please specify*
DENTAL/ORAL HEALTH
Does your child regularly see a dentist?*
- Yes
- No
How often?*
Does your child allow you to brush his/her teeth?
- Yes
- No
Has your child used a pacifier?
- Yes
- No
At what age did the child stop?
Pacifier currently used?
- Yes
- No
Pacifier brand
Does your child put toys or objects in his or her mouth?
- Yes
- No
BEHAVIORAL CONCERNS
Please check all that apply
Please check all that apply
- Cries often
- Dislikes hair brushing
- Rocks self
- Frequent temper tantrums
- Dislikes tooth brushing
- Is sensitive to light
- Poor attention span
- Sensitive to Sound
- Anxious
- Has trouble making friends
- Avoids touch from others
- Trouble with changes in routine
- Always “on the go”
- Clumsy
- Weak Muscles
Comments
Is there anything else that you feel would be beneficial for us to know about your child?
EDUCATIONAL INFORMATION
Did you child attend daycare or preschool?*
- Yes
- No
Does your child have an IFSP?*
- Yes
- No
CONSENT
Please read and initial each item:
CONSENT TO TREAT*
I give consent for my child to receive the necessary evaluation and/or treatment by Chatterbox Pediatric Therapy.
RELEASE/REQUEST*
Permission is given to Chatterbox Pediatric Therapy to release and/or request information when necessary for the records of the above-named individual.
CONTACT INFORMATION*
I give consent to leave messages on my voicemail or reminder text messages at preferred number.
VIDEO SURVALLIANCE ACKNOWLEDGEMENT*
In an aid to enhance the quality of care, Chatterbox Pediatric Therapy may use an electronic surveillance system to record visual occurrences on the facility’s internal and external grounds, the only exception being private areas of restrooms. I acknowledgement that I am aware that Chatterbox Pediatric Therapy may use an electronic surveillance system and I understand that video surveillance may be used for training, saftey, and investigative purposes.
EMAIL CONSENT FOR APPOINTMENTS AND BILLING*
I acknowledge that Chatterbox can contact me through email for appointment, financial, and treatment updates. I understand the risks that are associated with using this form of communication, including but not limited to information regarding your child’s treatment may be accessible to other parties on the web. Chatterbox will use reasonable means to protect the information sent and received by email and will treat such email messages with the same degree of confidentiality as medical records. I understand that Chatterbox cannot guarantee the security and confidentiality of email communications and I still request to use this form of communication knowing risk factors. I may withdraw this consent at any time by written communication with the office manager. I understand that by completing this information I will be enrolled in the patient portal through Fusion Web Clinic.
- I would like to receive my billing and financial statements through email
*
- I understand the practices and policies of Chatterbox Pediatric Therapy that I have initialed above
PRIMARY INSURANCE
Insurance Company
Member ID number
Policyholder's Name
Group ID
Relationship to Policyholder:
Employer
Insured’s Address: if different from child’s
Street Address Address Line 2 City State ZIP Code
Date of Birth: (policy holder’s)
Month
Day
Year
SECONDARY INSURANCE
Insurance Company
Member ID number
Policyholder's Name
Group ID
Relationship to Policyholder
Employer
Insured’s Address: if different from child’s
Street Address Address Line 2 City State ZIP Code
Date of Birth: (policy holder’s)
Month
Day
Year
Effective July 2021 Chatterbox Pediatric Therapy will require every family with patient responsibility (private pay, co-pay/deductible amounts) to have a credit card on file. Co-payments and deductible plan pre-pays amounts will be run each Friday for that week’s appointments. Chatterbox requires that all patient balances remain below $300. Please list the credit card information below that you would like on file for your child. You may also verbally provide this to the office when you check in for your evaluation. You may change your method of payment any time.
Name on Card*
Card Number*
Expiration Date*
CVV (number on back of card)*
Zip Code*
- I understand that patient responsibility for services provided by Chatterbox are due at the time services are rendered. I give Chatterbox Pediatric Therapy permission to charge my credit card listed above for copays/deductible plan pre-pays or any other financial payment plan arrangements made with Chatterbox Pediatric Therapy for services provided to my child.
Assignment of Benefits:*
Chatterbox Pediatric Therapy will make every effort to work with our clients regarding obligations for services whether payment may be through insurance, private pay, co-payment or other agreements.
- I certify that the information given by me in applying for payment is correct. I hereby authorize payment by my insurance carrier of the benefits, otherwise payable to me, to be made directly to Chatterbox Pediatric Therapy for their services.
*
- I authorize Chatterbox Pediatric Therapy to release all insurance companies and/or compensation carriers only such as diagnostic, therapeutic, and financial information as may be necessary to determine benefits entitled and to process payment claims for health services that will be provided.
*
- I understand and agree that I am financially responsible for all co-pays, coinsurance and amounts not covered by my healthcare provider. This charge is expected at time of services.
*
- I understand that I am obligated to provide ALL insurance information and must notify Chatterbox immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.
Attendance/Cancellation Policy

We are thankful that you have entrusted your child’s care to us. We hope that you will find your experience with Chatterbox Pediatric Therapy to be a fun and positive one. It is very important that your child attends each session in order to make consistent progress.

Consistent attendance to therapy sessions allows routine practice of skills targeted in therapy as well as facilitates faster progress towards their therapy goals. When children do not have consistent attendance, their progress slows, and they are more likely to regress during these periods of time when they are not receiving services.

In following the policy below, you are helping to ensure your child is regularly attending therapy to meet their goals. This policy also allows us ample time to offer any open times to children waiting for services.
CORRESPONDENCE*
All correspondence regarding cancellations and rescheduling of therapy appointments must go through the front office. Families may notify clinician as well as a courtesy but are responsible for contacting the office.
ARRIVAL TIME*
Please arrive on time for your scheduled appointment to receive your full treatment time. If you are more than 10 minutes late, your appointment will need to be rescheduled.
CHECK IN*
Parents must complete the text check in and screening process prior to being seen for any appointments. Parents are not allowed to check in prior to arriving at the facility.
24 HOURS NOTICE*
A minimum of 24 hours' notice is required for non-emergencies.
RESCHEDULING*
Families are expected to make every attempt to reschedule any non-illness related missed appointments in order to remain on the reoccurring schedule.
EMERGENCIES*
If an emergency occurs after our normal business office hours, please leave a message on the answering service, enabling us to follow up to reschedule your appointment and ample time to notify the treating therapist(s).
CALL IN SICK*
Please do not bring your children to therapy when they are ill. Children must be free of fever (without use of fever reducing medication), nausea or vomiting for 24 hours prior to returning to therapy.
ATTENDANCE*
Patients with attendance below 80% of scheduled appointments will result in being removed from reoccurring appointments. This is the equivalent of missing more than 2/10 appointments for 2x a week or more than 1/5 1x a week appointment.
NO CALL - NO SHOW*
Two consecutive No Call-No Show appointments will result in immediate removal from the reoccurring schedule.
ATTENDANCE POLICY*
Repeated failure to comply with this Attendance Policy will result in your child losing their regularly scheduled therapy times and moved to our flex scheduling option. This will require you to call for an open appointment on each week/day you would like to receive therapy. We will do everything possible to accommodate you as space on the schedule permits.
CANCELLATION FEE*
In the event that my child receives more than one therapy service (speech, occupational, physical), I understand that each one follows an individualized plan of care specific to my child's needs. It is important that they attend every scheduled appointment to address all areas of development needed to help my child improve. In the event that a clinician is out, resulting in one of the appointments to be cancelled, I understand that the office will do their best to reschedule with another clinician to help provide continuity of care. Should I decline to reschedule and/or cancel my child's other appointments in such a situation, I understand that the attendance policy will be applied, and a no show/late cancellation fee may be assessed for each scheduled appointment that is not kept.
No-Show/Late Cancellation Fees may be charged for repeat offenses of the following situations:
Cancellation Fees*
Failure to show for a scheduled appointment without proper notification of absence.
Cancellation Fees 2*
Failure to notify office of cancelled appointments within 24 hours of the scheduled appointment when applicable.
Cancellation Fees 3*
Chronic arrival to appointments beyond the 10-minute mark, resulting in cancellation of therapy.
Cancellation Fees 4*
A $65 No-Show/$40 Late Cancellation fee will be applied for failure to follow our attendance policy. For patients with multiple appointments in one day, the fee will not exceed $100 per day.
Cancellation Fees 5*
Families are allowed these fees to be waived for one date of service per quarter.
Cancellation Fees 6*
These fees may be waived in the circumstance that a no-show or late cancelled appointment is rescheduled and kept within one week of the missed appointment. Full payment of any assessed cancellation fees must be paid in full before your child may return to their regularly scheduled appointments and moved to flex scheduling. unpaid no show or late cancellation fees over 90 days may result in turning the account over to a third-party collection agency.
We appreciate your cooperation and compliance with our attendance policy. We look forward to working together to help your child reach his/her full potential.

By signing, I acknowledge that the above has been reviewed with me and I have full understanding of the attendance policy.
Child Name*
Parent/Guardian Name*
Parent/Guardian Signature*
Date*
Month
Day
Year
I GIVE CHATTERBOX PEDIATRIC THERAPY PERMISSION TO DISCLOSE MY CHILDS HEALTH INFORMATION TO:
Name Of Person (i.e family member) Relationship to Patient
Chatterbox has our Privacy Policy posted in the waiting areas of each location and available for review at the time of check-in. Please let the office know if you would like a copy to take home with you. You can review the online copy here at any time.
Does your child receive school therapy services or early intervention services through an IEP or IFSP?*
- Yes
- No
Name Of School*
If yes, do you give Chatterbox permission to obtain the IEP or IFSP?*
- Yes
- No
Many insurances require IEPs and IFSPs for authorizations and payment for therapy services. Therefore, failure to allow Chatterbox to obtain these records may prevent your child from receiving services at Chatterbox Pediatric Therapy.
Release of Medical Records
I hereby request the release of records from the following entity (Please list child's school if they have an IEP)
Organization Name
Fax Number
Contact Person
Documents Requested
To be released to:
Chatterbox Pediatric Therapy, LLC 110 Pipemakers Circle, Suite 115 Pooler, GA 31322 Fax Number: 912-988-1537 Attention: Medical Records
Chatterbox Pediatric Therapy, LLC 2453 G US Highway 17 South Richmond Hill, GA 31324 Fax Number: 912-445-5653 Attention: Medical Records
Parent/Guardian Name*
Parent/Guardian Signature:*
Date*
Month
Day
Year
PHOTO RELEASE ACKNOWLEDGEMENT*
- I, the parent or legal guardian DO grant Chatterbox Pediatric Therapy my permission to use the photographs taken during therapy for any legal use, including but not limited to publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
- I, the parent of legal guardian DO NOT grant Chatterbox Pediatric Therapy my permission to use any photographs of my child taken during therapy for any public purposes, including but not limited to publicity, advertising and web content.
Please initial here*
Child Name*
Parent/Guardian Name*
Parent/Guardian Signature:*
Date*
Month
Day
Year

Case History – Birth To 3 Years

Case History – Birth To 3 Years

FAMILY

SCHEDULE

PRE-NATAL & BIRTH HISTORY

DEVELOPMENTAL MILESTONES

HEARING

VISION

DENTAL/ORAL HEALTH

BEHAVIORAL CONCERNS

EDUCATIONAL INFORMATION

CONSENT

PRIMARY INSURANCE

SECONDARY INSURANCE

Attendance/Cancellation Policy

No-Show/Late Cancellation Fees may be charged for repeat offenses of the following situations:

Release of Medical Records

Our Locations

Pooler

Richmond Hill

Name	Age

Name	Nickname

Name	Day	Time

Surgery	Date

Case History – Birth To 3 Years

FAMILY

SCHEDULE

PRE-NATAL & BIRTH HISTORY

DEVELOPMENTAL MILESTONES

HEARING

VISION

DENTAL/ORAL HEALTH

BEHAVIORAL CONCERNS

EDUCATIONAL INFORMATION

CONSENT

PRIMARY INSURANCE

SECONDARY INSURANCE

Attendance/Cancellation Policy

No-Show/Late Cancellation Fees may be charged for repeat offenses of the following situations:

Release of Medical Records

Have Questions? Contact Us

Our Locations

Pooler

Richmond Hill

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