Beyond Speech Therapy

Welcome to Beyond Speech Therapy! Thank you for choosing Beyond Speech Therapy to help meet your speech language pathology needs. We realize there are many options from which to choose and we appreciate the opportunity to assist you with this important process. The attached New Client Paperwork packet includes important information about this practice including insurance, financial and privacy policies. Please take time to fill out as much information as possible regarding your history as this information can be vital to the direction of the therapy plan. We understand that these forms can be time consuming, however it is important that your therapist have as much information as possible prior to your first visit so that she may provide the best possible service for you. If you have had any recent evaluations completed by other health professionals (psychologist, ENT, Oncologist, Gastroenterologist etc.), please bring copies of these with you or you may fax or email them to Beyond Speech Therapy in advance. Completed packets may be faxed to 805-591-7189 or mailed to 6965 San Luis Ave, Atascadero, CA 93422 or emailed to [email protected] For more information about our services, please visit www.Beyondspeechtherapy.net We look forward to meeting you! Sincerely, April Nolan M.Ed., CCC-SLP CA License 15939 ASHA # 12085182 Speech Language Pathologist Owner of Beyond Speech Therapy 6965 San Luis Ave, Atascadero, CA 93422 Phone (805) 591-7188 Fax (805) 591-7189 www.beyondspeechtherapy.net



Beyond Speech Therapy

Biofeedback Intake Questionnaire Legal Name: _________________________________________Date: ____________________________ Preferred Name: _______________________________________________________________________ Primary Patient Complaint: ______________________________________________________________ Are you receiving any other treatment for this condition? Yes _____No_____ If yes, where and with whom?_______________________________________________________ Check any of the following stressors that currently apply: Work _____ School _____ Family _____ Relationships _____ Financial _____ Health Concerns _____ Living conditions _____ Legal _____ Schedule overload _____ Other ___________________________________________________________________________ How do you relax? _____________________________________________ How often? _____________ Check the following symptoms that currently apply: Migraine headaches _____ Tension headaches _____ Dizzy spells _____ Cold hands/feet _____ Nervousness _____ Abdominal discomfort _____ Sweat (not due to heat) _____ Panic Attacks _____ Increased Heart Rate _____ Worrying _____ Hyperactivity _____ Attention Problems _____ Difficulty Focusing _____ Muscle tension _____ If yes, where?_________________________________________________ Specific Anxiety _____ If yes, describe: _______________________________________________ Change in sleep patterns _____ If yes, describe: ________________________________________ List any other concerns __________________________________________________________________ List current medications and reason: _______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ List any additional vitamins or supplements: _____________________________________________________________________________________

Beyond Speech Therapy Do you smoke? Yes_____ No_____ Amount _______________________________________________ Describe your average alcohol consumption: ________________________________________________ How much caffeine do you consume daily?: _________________________________________________ Have you previously received biofeedback? Yes_____ No_____ Rate your stress level for today 1 2 3 4 5 6 7 8 9 10 (1=lowest level, 10=highest level) Is this typical? Yes_____ No_____



Beyond Speech Therapy

POLICIES AND PROCEDURES ______CANCELLATION POLICY: If you must cancel an appointment, please call immediately. Except under emergency circumstances and acute illness, all appointments cancelled with less than 24-hour notice will be subject to a service fee of $85 for evaluations and $65.00 for therapy sessions. There will be ONE “Failure to cancel/NO show” courtesy provided. If you arrive late for your appointment, we will do our best to see you, however the appointment may be shortened due to the therapist’s schedule; the full session fee still applies. Please note that most insurance companies will not reimburse for missed appointments and you will remain responsible for these charges.

If you need to bring children to the clinic, please have them use their inside voices in the waiting room and be respectful of our space, so as not to disturb others in session or waiting in the shared space. _____PAYMENT The person who completes the Party Responsible for Payment section is responsible for payment of all services rendered. In most cases, payment is due at the time services are rendered unless you have made other arrangements in advance. Accounts more than 45 days overdue will be subject to a $20 late fee and 5% interest charge. Accounts more than 90 days overdue will be sent to collections. For clients seeking third-party reimbursement, please be aware that you are ultimately responsible for the payment of services rendered. If your insurance carrier denies payment (including recoupment) or does not remit payment within 45 days, the client will be responsible for payment of all services rendered. Prior to your initial visit, please contact our office to obtain an estimate of charges and out of pocket expenses. Fees apply to various types of services including but not restricted to direct client contact (clinic based or offsite), phone consultations, travel, and consultation with other professionals. I understand that my authorization will remain effective from the date of my signature until ___________, and that the information will be handled confidentially in compliance with all applicable HIPPA and federal privacy laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written and dated communication. I have read and understand the nature of this release. Patient’s/Representative’s Signature: ___________________________Date: ___________________ Witness: __________________________________________________ Date: ___________________

Beyond Speech Therapy ______Informed Consent, Statement of Client Rights and Confidentiality: Before beginning biofeedback therapy, you are legally entitled to an explanation (in terms and phrases that you understand) of what is going to happen to you so that you can give what is called “informed consent.” Informed consent is obtained to encompass assessment procedures, treatment procedures, billings and fee collections, and procedures to protect confidentiality, as well as conditions that limit confidentiality. Biofeedback is a technique for making unconscious and involuntary bodily processes (i.e., heartbeats and skin temperature) perceptible to the senses (by the use of sensitive recording machines) in order to influence them through conscious mental control. Caution and common sense are required when attaching recording sensors to you. Your permission must be given before touching body areas considered appropriate within the realm of common practice of biofeedback therapy. The information that you share with your biofeedback therapist is confidential and will not be divulged to anyone without your written consent. However, this policy does not apply in the following circumstances: 1. If you have insurance coverage and an assignee of your EAP, insurance company or employer requests information about your case, information will be shared if you indicated a willingness to do so by your signature on your insurance form. 2. If information is revealed which might indicate that you present a clear and imminent danger to yourself and/or another individual(s) we are obligated to report this information to a designated government agency. 3. If information is revealed which might indicate that you have physically, sexually or emotionally abused a child, adolescent or senior citizen, we are obligated to report this information to a designated governmental agency. 4. If your provider is an employee of Beyond Speech Therapy, and is regularly supervised, information pertinent to your case may be discussed with the Supervisor who will then be held accountable to this Policy of Confidentiality. If you have any concerns or questions regarding this policy, please discuss them with your biofeedback therapist. By signing this document, you acknowledge that you have read, understood and accept this Informed Consent, Statement of Client Rights, Welfare and Confidentiality. Patient’s/Representative’s Signature: ___________________________Date: ___________________ Witness: __________________________________________________ Date: ___________________

Biofeedback Intake Questionnaire.pdf

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