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Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 Dear Parent/Guardian: Thank you for choosing Children's Therapy Clinic, Inc. (CTC) for your child's care. Enclosed you will find several forms to be filled out. The purpose of these forms is to determine eligibility to the program and to obtain records on your child from other doctors, hospitals, etc., before your child's appointment. If you have questions after reviewing these documents, please call the director, Valicia Leary, at (304) 342-9515. In order to process your child's paperwork more efficiently, a list of instructions is provided below. A. Intake Form Please fill in the blanks on both pages of the form. Please contact your child's physician to obtain a written order for treatment (usually on a prescription form) before your child's first visit to the Clinic. This information must be received before a visit will be scheduled for your child. B. Insurance Verification Form Please complete all sections of this form. If it is possible for you to do so, please send a copy of your child's insurance card (front and back). If your child does not have insurance, please indicate this on the form. Please sign and date the form. C. Statement of Understanding – Form A and Application for Admission to Program – Form B The mission of CTC is to provide therapeutic services to children, ages birth to twenty-three, who fall into one of the following categories: (1) Economically disadvantaged and/or (2) Children having insufficient or no insurance coverage for their condition. Children's Therapy Clinic charges fees for services using a sliding scale based on the Federal Poverty Level guidelines. Applicants are required to provide income information. Please complete all lines of the Statement of Understanding – Form A and the Application for Admission to the Program – Form B and send a copy of your most recent Federal Tax Return with your application. Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 If your child qualifies for admission to the program based on insufficient insurance coverage, you will be required to provide the following information: (1) a denial letter from the insurance company, or (2) direct confirmation of such through the insurance verification process. For the purposes of this policy, insufficient insurance coverage is defined as follows: The number of therapy sessions ordered by the physician exceeds the number of therapy sessions covered by the insurance company. Please fill in the blanks reading the form carefully, then sign and date the form. D. Health Information Record and Doctor Prescription Please have your child's physician complete the Health Information Record and write a prescription for the therapy type(s) you are applying for. Thank you for your assistance. Valicia Leary Executive Director Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 INTAKE FORM Child's Name _______________________________ Date of Birth ____________ Age ____ Today's Date ____________ Child's Ethnicity: (This information is used only for grants requiring statistical reports and is reported anonymously.) White /Caucasian Black/African-American Hispanic Asian Multi-Racial / Multi-Ethnic Other Parent or Guardian 1 Name:____________________________________________ Phone Numbers (home) ___________________________________ (work) ____________________________________ (cell / alternative)_________________________ email address: ____________________________ Address: __________________________________________ City:_______________________ State_____ Zip_________ County:______________________________ Parent or Guardian 2 Name:____________________________________________ Phone Numbers (home) ___________________________________ (work) ____________________________________ (cell / alternative)_________________________ email address: ____________________________ Address (if different from above): ______________________ City:_______________________ State_____ Zip_________ County:______________________________ * Appointment Reminder: Children's Therapy Clinic may attempt to call you to confirm an appointment. Due to the confidential nature of your visits, we need your permission to call. May we call to remind you of appointments? Yes No May we leave a message? Yes No Child's Physician_____________________________________ Telephone _________________________________ PLEASE HAVE PHYSICIAN SEND AN ORDER OR PRESCRIPTION FOR EVALUATION AND TREATMENT TO: Children's Therapy Clinic 113 Lakeview Drive, Charleston, WV 25313 Reason for Referral (Diagnosis) ___________________________________________________________________ Is your child involved with other agencies? __________ Please list ____________________________________ __________________________________________________________________________________________________ Primary Insurance ______________________________ Secondary Insurance ____________________________ Does your child receive benefits from Title 19 Waiver? No Yes Agency: _________________________________________________________________________ Previous Therapy Received _______________________________________________________________________ Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 Applying based on: (check one) Income No Insurance Insufficient insurance coverage for condition (please attach denial letter.) Needs: (check all that apply) Physical Therapy Occupational Therapy Speech Therapy Autism Socialization Group Music Therapy School _____________________________________________________Grade _______ School Address ___________________________________________________________ Referral Screening Questions 1. Has your child had any major medical problems? _______________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 2. Are there concerns about your child's hearing and/or vision? ____________________________________________ __________________________________________________________________________________________________________ 3. Do you feel that your child is doing the same things as other children his or her age (e.g., crawling, walking, etc.)? ___________________________________________________________________________________________________ _________________________________________________________________________________________________________ 4. Does your child use any assistive devises (e.g., wheelchair, braces, walker, splints, etc.)? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Do you have any concerns about these?____________________________________________________________________ 5. How does your child participate in feeding? ______________________________________________________________ ___________________________________________________________________________________________________________ 6. What types of toys does your child play with? How does he/she play with them? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 7. How does your child communicate? ____________________________________________________________________ ___________________________________________________________________________________________________________ 8. What does your child do when he/she is frustrated or angry? _______________________________________________ ____________________________________________________________________________________________________________ Signature of Parent/Guardian___________________________________ Date _______ Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 INSURANCE VERIFICATION FORM Prepared by: ____________________________________________________ Date: _____________________ x Please send a copy of your child's insurance card with application. Child's Name: ID#: Subscriber Name: Subscriber ID#: Group #: Insurance Company: Address: Telephone Number: Effective date of policy: Family Coverage? _____ Yes _____ No Date Terminated: Deductible amount: Amount of deductible met: Therapy Services Covered: Type of Service Service Limits Physical Therapy Occupational Therapy Speech Therapy Specialty Services Other Signature of Parent/Guardian: _______________________________________________ Date: ______________ Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 STATEMENT OF UNDERSTANDING – FORM A The information I have given concerning the size of my family and my family's gross annual income from all sources is true, accurate and complete to the best of my knowledge. I have given this information concerning my financial situation and my means and ability to pay for the purpose of procuring therapeutic services for ______________________. I understand that Children's Therapy Clinic, Inc. will rely on such information to determine ______________________'s eligibility to the program. I understand that knowingly giving false information in this case may result in criminal prosecution under the laws of the State of West Virginia. I agree to report any change in either my income or my family size to Children's Therapy Clinic, Inc. (CTC) before or at the time of my next contact with the Clinic. I know that the information I have given will be relied upon until it is changed. I understand that ______________________'s eligibility status will be reviewed on an annual basis and adjusted according to my family income and size at the time of review. If CTC has reason to suspect that the information I have given is untrue, incomplete, or inaccurate or that I have not properly reported changes, CTC may initiate a review of ______________________'s eligibility and I will authorize access to all my financial records. If I refuse such review or authorization, CTC will no longer provide services to my child/ward. Parent/Legal Guardian Signature: ____________________________________________ Date:_________________ **FOR OFFICE USE ONLY** DETERMINATION OF ELIGIBILITY After careful examination of the applicant's family size, family situation, and financial situation, it is my decision that this application for services be: Granted Denied This determination shall remain in effect for one year from this date, at which time the applicant's financial situation will be reviewed to re-evaluate eligibility. Authorized by: ____________________________________ Date: ______________ Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 APPLICATION FOR ADMISSION TO PROGRAM (FORM B) Please note that the information requested on this form will be used to determine eligibility for services at Children's Therapy Clinic. It will be reviewed by the Executive Director. Head of Household _____________________________ Date of Birth __________ Please list all members of household (including client) _________________________________________________ _____________________________________________________ _________________________________________________ _____________________________________________________ _________________________________________________ _____________________________________________________ _________________________________________________ _____________________________________________________ Head of Household's Employer: _____________________________________________ Spouse's Employer: ________________________________________ Employer's Phone Number: ______________________ Employer's Phone Number: ______________________ Employer's Address: _____________________________ _________________________________________________ Employer's Address: _____________________________ _________________________________________________ * copy of latest Federal Tax Return must accompany this form Family Income Determination Income Sources: Amount Yearly Wages- Head Yearly Wages- Spouse $___________ $___________ Social Security Pensions/Annuities $___________ $___________ Personal Business Profits $___________ Welfare $___________ Seasonal Employment $___________ Aid to Dep. Children $___________ Disability/Insurance $___________ Alimony $___________ Unemployment Payments $___________ Child Support $___________ Veteran's Benefits $___________ Food Stamps $___________ Other (Specify) $___________ Total Annual Income: $______________________ Children's Therapy Clinic · 113 Lakeview Drive Charleston, WV 25313 www.childrenstherapyclinic.com · Phone 342-9515 · Fax 342-9414 HEALTH INFORMATION RECORD (MUST be completed by child's physician) Name: ___________________________________________ Date of Birth: _____________________ Address: _________________________________________ Phone: ____________________________________________ City: _____________________________________________ Parents: ___________________________________________ State: ____________________ Zip: _____________ ___________________________________________________ ALLERGIES: Medications: ____________________________________________ Reaction: ______________________ Foods: __________________________________________________ Reaction: ______________________ MEDICATIONS & RESTRICTIONS: Current Medications: __________________________________________________________________________ Dietary Concerns: _____________________________________________________________________________ Activity Restrictions: ___________________________________________________________________________ SIGNIFICANT HEALTH ISSUES (circle all that apply): Seizures Asthma Diabetes Other: __________________________ EMERGENCY CONTACT INFO: Name : ____________________________________________ Relation: ______________________ Phone: ____________________________ Physician: _________________________________________ Physician's Phone: ________________________________ IMMUNIZATION RECORD Immunization Enter Dates of Immunization Dtap _______ _______ _______ _______ _______ Polio _______ _______ _______ _______ MMR _______ _______ Hib _______ _______ _______ _______ HepB _______ _______ _______ Varivax _______ _______ Immunizations up to date? yes no (catch-up schedule: _____________________________________) Physician Name: _____________________________ Signature: _______________________ Date: ____________ SLIDING SCALE FEES Family income below 200% of the Federal Poverty Level (FPL) = no fee Family income between 200% and 250% of FPL = $5 per therapy session Family income between 251% and 300% of FPL = $10 per therapy session Family income between 301% and 500% of FPL = $25 per therapy session Family income above 500% of FPL = $50 per therapy session Waiver of any of the above fees will be considered on an individual case basis by the Finance Committee.

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