Intake Questionnaire

Child's Name *

First

Last

Child's Date of Birth *

please enter month/day/year

Parent/Guardian Name(s) *

Home Address *

Phone Number *

Email *

Pediatrician Name and Number *

How did you hear about Move Pediatric Therapy?

Does your child have a diagnosis? If so please list all diagnoses. *

Did you or your child experience any complications during pregnancy or birth? If there were complications please describe them. *

Was your child born prematurely? *

If you answered "yes" to the question above please state at what gestational age (in weeks) your child was born.

Did your child spend any time in the NICU? *

If you answered "yes" to the question above how many weeks did your child spend in the NICU? Please provide details about their stay.

Please describe or list your child's current gross motor strengths. *

Please describe or list your child's current gross motor concerns. *

Does your child use any adaptive equipment? If they do please list the types of equipment (example: orthotics, stander, hearing aides, etc). *

Please list the medications your child currently takes and how often they take them. *

Has your child had any surgeries? If so please state the procedure and the date it was performed. *

What other medical specialists work with/follow your child? *

Does your child currently receive physical therapy? Have they received PT services in the past? If so please state where they received services and for how long. *

What are your goals for physical therapy? *

Is there anything else you would like us to know about your child?

Media Release Form

I hereby grant permission for Move Pediatric Therapy, LLC to use images of my child in the following ways which are designated below. Images will be used for marketing purposes for Move Pediatric Therapy, LLC and to provide therapeutic education to other parents. Please indicate the following items that you consent to below by checking on the boxes that apply. *

use of my child’s photos/videos on facebook and instagram
use of my child’s photos/videos on the Move Pediatric Therapy website
I do NOT consent to use of my child’s photos or videos for any purposes

If you provide consent for your child's photos and videos to be used for any purpose above please indicate how you would like your child displayed.

photos and videos with my child’s face displayed fully
photos and videos with my child’s face blurred out
photos and videos of my child’s back/back of head only

If you provide consent for your child's photos and videos to be used for any purpose above please indicate how you would like your child to be addressed/identified.

I prefer my child’s first name be used
I prefer that only my child’s first initial be used
I do not want my child’s first name or an initial to be used

Child's Name *

First

Last

Parent/Guardian Name *

First

Last

New Patient Acknowledgements

Consent to Treatment *

I consent to and authorize licensed physical therapists from Move Pediatric Therapy, LLC to administer rehabilitation therapy techniques, treatments and modalities to my child/minor. I understand and am informed that, as in the practice of medicine, rehabilitation therapy may have some risks including minor or significant injury. I understand that I have the right to ask about these risks and my child’s treatment plan at any time. I know it is up to me to inform my physical therapy provider about any health problems my child has, precautions or contraindications to therapeutic activities that may impact my child, as well as medications my child is currently taking. I acknowledge that no guarantees have been made to me regarding my child’s treatment and/or treatment results. *Please place your initials in the box above*

Privacy Notices *

I hereby acknowledge that I have been made aware of Move Pediatric Therapy, LLC privacy practices. Move Pediatric Therapy, LLC will never use or disclose your child’s private health information without permission from a parent/guardian. Explicit details as to how this information will be used and protected is available. *Please place your initials in the box above*

Authorization to Release/Obtain Medical Information *

I hereby authorize the release of my child’s health care information for the purposes of treatment and continuity of care, to my child’s physician or other health care providers pertinent to my child’s medical care. Further, I authorize Move Pediatric Therapy, LLC to obtain needed information from my child’s pediatrician, specialty physicians, or other health care facilities or providers that are pertinent to my child’s care. Specific medical professionals and facilities that Move Pediatric Therapy, LLC has been authorized to contact or receive information from are typed above (please provide as detailed information as possible). Correspondences can be made via mailings, telephone, email or facsimile. *Please place your initials in the box above*

Financial Responsibility *

I understand that payment is due at the time of treatment. I agree to pay Move Pediatric Therapy, LLC all amounts that are due for services rendered. In the event that my account is referred to a collection agency or an attorney, I further agree to pay all costs incurred during this process. If my child is participating in an intensive therapy program 25% of the total amount is due at the time of booking. *Please place your initials in the box above*

Cancellation Policy *

We advise that you schedule your appointments in advance whenever possible. Maintaining a consistent schedule ensures the best outcome for your child. We expect you to keep all of your appointments with Move Pediatric Therapy, LLC and require a 24 hour notice if you are unable to keep an appointment. If your child is participating in an intensive session and you need to cancel you MUST reach out to Move Pediatric Therapy, LLC more than 30 days prior to the first day of the intensive. There will be no refund provided if notice is given within 30 days of the intensive program start date. *Please place your initials in the box above*

Child's Name *

First

Last

Parent/Guardian Name *

First

Last

Electronic Signature (please type) *

Today's Date *

Intake Questionnaire

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