47 - New Client Checklist Step 1 of 3 33% Patient's (person receiving services) First Name(Required)Patient's (person receiving services) Last Name(Required)Patient's (person receiving services) Date Of Birth MM slash DD slash YYYY Parent/Guardian First Name(Required)Parent/Guardian Last Name(Required)Address(Required) Street Address Address Line 2 City State Zip Code Primary Phone(Required)Email(Required) Doctor(Required) Name Doctor's Phone(Required)Location and Name of Dr. Office/Facility(Required)Has child received a free screening? Yes, at Kidworks Yes, other facility No Did child participate in the First Steps Program? Yes No Has child received previous therapy services? Yes No Please describe(Required)Does the child have any medical diagnoses? Yes No Please describe(Required)Has the child had a recent surgery? Yes No Date of surgery MM slash DD slash YYYY Please describe(Required)Primary Insurance(Required)Member ID(Required)Group #Secondary InsuranceMember IDGroup # Type Of Therapy RequestedOccupational Therapy Yes No Concerns(Required)Does your child seem to struggle or avoid textures of clothing, food, self-care tasks (nail clippings, washing hair, brushing teeth)? Yes No Does your child appear to struggle sitting still to focus on learning tasks, meals, going to bed, etc.? Yes No Does your child seem overstimulated by noise, lighting, crowds, clothing, etc.? Yes No Does your child excessively run, jump, flap, crash, seek contact from you what appears excessively? Yes No Does your child struggle transitioning or being told "no"? Yes No Does your child have frequent tantrums when told "no" or something being taken away from them? Yes No Does your child have behaviors such as hitting, spitting, kicking, head banging? Yes No Speech Therapy Yes No Concerns(Required)Feeding Therapy Yes No Concerns(Required)Does the child have trouble chewing, and swallowing? This may include choking, gagging, coughing, holding food in their cheek, spitting food out, mashing or sucking on food. Yes No Does the child have difficulty transitioning from baby food to solid foods? Yes No Does the child have difficulty transitioning off bottle or breast? Yes No Does the child cough or choke on liquids Yes No Does the child refuse food even if it is favorite food? Yes No Does the child have an excessive intake of milk or PediaSure? (over 24 ounces a day) Yes No Does the child have a feeding tube? What type- NG, GT, JT? Yes No What kind of feeding tube?Does your child need thickeners in their liquids? Yes No Is your child under 18 months Yes No Does your child struggle in gaining or losing weight? Yes No What is your child’s current weight?Nutrition Therapy Yes No Concerns(Required)Physical Therapy Yes No Concerns(Required)Developmental Therapy (Ages 2-6) Yes No Concerns(Required)Does your child has the following concerns: One sided weakness Stroke Brain Injury Any type of surgery CP/Cerebral Palsy Gagging, choking, vomiting Low or high muscle ton Upper extremity injury/surger G-Tube NG-Tube Torticollis Requesting Specific Therapist(s)? Yes No Therapist's NamePreferred Appointment TimeBefore 3:00 pmAfter 3:00 pmDay That Works BestParent Concerns/Notes:(Required)How did you hear about Kidworks? HIPAA Notice of Privacy PracticesThis Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment. Your Rights: Following is a statement of your rights with respect to your protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact with your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We welcome your comments. Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.Consent(Required) I agree. Δ
