First Name *
Middle Initial/Name
Last Name *
Birth Date *
Gender * (as listed on ins. card) MaleFemale
Preferred Pronouns
Address 1 *
Address 2
City *
State *
Zip *
Home Phone
Cell Phone
Allow Text Messages YesNo
Email *
Spouse/Caregiver #1
Name
Relationship
Occupation
Birth date
Spouse/Caregiver #2
Please list any current medications
Do you currently see any other medical specialists (physicians, audiologists, psychologists, etc.)
List any frequently occurring medical problems
List any significant illnesses injuries or hospitalizations
Have you received a COVID-19 vaccine? YesNoPrefer not to say
If not, please explain:
Auditory, Speech and Language Please describe any auditory speech and/or language difficulties/concerns:
Have you ever undergone an auditory speech and language evaluation? -- Select Yes or No --YesNo
If yes, date(s) of testing:
Performed by:
Results:
Have you ever previously received auditory speech and language treatment? -- Select Yes or No --YesNo
What is the primary language spoken at home
Is any language other than English spoken in the home NoYes
If Yes please list the languages
Overall Skill Development
Please indicate how you feel about your behavior/development in the following areas:
Gross Motor Below AverageAverageAbove Average
Description:
Fine Motor Below AverageAverageAbove Average
Feeding/Swallowing Below AverageAverageAbove Average
Description
Social Interaction Below AverageAverageAbove Average
Vision Below AverageAverageAbove Average
Hearing Below AverageAverageAbove Average
Self-Help Skills Below AverageAverageAbove Average
Description Skills
Authorized Signature Release Form Please read the Island Wide Speech Authorized Signature Release Form
I have read and agreed to the Island Wide Speech Authorized Signature Release Form. I agree
Attendance Policies and Sick Procedures Please read the Attendance Policies and Sick Procedures at Island Wide Speech
I have read and agreed to the Attendance Policies and Sick Procedures at Island Wide Speech. I agree
Teletherapy Please read the Island Wide Speech Teletherapy Consent Form
I have read and agreed to the Teletherapy Consent Form for Island Wide Speech. I agree
Notice of Privacy Practices Please read the Island Wide Speech Notice of Privacy Practices
I have read and agreed to the HIPAA Notice of Privacy Practices for Island Wide Speech. I agree
I understand it is my choice to attend sessions at Island Wide Speech either through insurance or private pay.
-- Please select one --I opt to go through my health insurance for all services at Island Wide Speech.I opt to pay privately for all services at Island Wide Speech. I am choosing not to go through my health insurance.
Insurance Policy Questions
Please read the Insurance Policy Questions to ask your Insurance questions
If attending via insurance, I agree to call my provider and ask the above questions in regards to my policy’s coverage of speech therapy. I agree
Insurance Reimbursement Agreement
I understand that if my insurance denies reimbursement for claims submitted by Island Wide Speech, I will be responsible for all outstanding claims/payments. I agree
Primary Insurance
Please select your primary insurance: -- Please select one --CignaEmblemHealth - GHIEmpire BlueCross BlueShieldMagnacareMedicareOscarThe Empire Plan: NYSHIPUnitedHealthcareOther
Member ID:
Group ID:
Subscriber's First Name
Subscriber's Last Name
Subscriber's Birth Date
Subscriber's Gender (as listed on ins. card) MaleFemale
Upload Insurance Card Please send us a copy of the front and back of your insurance card.
Do you have a secondary insurance? YesNo
Secondary Insurance
Please select your secondary insurance: -- Please select one --CignaEmblemHealth - GHIEmpire BlueCross BlueShieldMagnacareMedicareOscarThe Empire Plan: NYSHIPUnitedHealthcareOther
Secondary Member ID:
Secondary Group ID:
Secondary Subscriber's First Name
Secondary Subscriber's Last Name
Secondary Subscriber's Birth Date
Secondary Subscriber's Gender (as listed on ins. card) MaleFemale
Upload Secondary Insurance Card Please send us a copy of the front and back of your secondary insurance card.
Upload your Prescription.
Please sign
Name of person completing form *
Relationship to client *
Please sign below: *
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Island Wide Speech · fara@islandwidespeech.com · (516) 415-2751 · Plainview, NY