Adult Intake Form - Erika Phillips - Speech Language Pathology

Name (First & Last) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Date of Birth *

Highest Level of Education

Marital Status

Spouse's Name (if applicable)

Children (Name, Age)

Who Lives In The home?

Languages Spoken

Dominant Language

Describe Your Speech-Language Difficulties

What Do You Hope To Achieve With Speech Therapy?

Have You Seen Any Other Specialists? (Physicians, Occupation Therapist, Physiotherapist, Neurologist, etc.)?

If yes, indicate the name of specialist, when you were seen, and the specialist's conclusions or suggestions.

Speech Language History (Please check all that apply)

Are There Any Other Difficulties Besides What Is Listed Above?

When Was The Problem First Noticed?

Did The Problem Begin Suddenly Or Develop Over Time?

How Or Where Does the Speech-Language Impact You The Most?

Describe Your Daily Communication Needs

Describe Your Interests and Hobbies

Medical History (Please Check All That Apply)

What Is Your Current State Of Health?

Excellent
Average
Poor

Describe Any Major Surgeries, Operations, Or Hospitalizations (Include Dates)

Please Provide Any Additional Information That You Believe To Be Helpful In The Evaluation or Remediation Process

How Did You Find Me?

Form Completed By

Relationship to Client

Terms and Conditions

I grant informed consent for Erika Phillips Speech Language Pathology’s Therapists to provide assessment, treatment and consultation to the client listed on this form. *

I understand and consent to Speech Language services.

No show or late cancellation

No shows will be billed at the full hourly rate. Cancellations within 24 hours will be billed at the full hourly rate. The fee may be waived if a make-up session is scheduled outside of the regular treatment frequency. *

I understand that I may be billed for no shows and late cancellations.

Investment

The rate charged by Erika Phillips Speech Language Pathology for the services listed below will begin at $170 per hour. All therapy sessions may be subject to indirect fees which can include 15 minutes of billable time. Indirect fees include consultation, treatment preparation, treatment documentation, coordination, etc. Services that will be invoiced according to Erika Phillips Speech Language Pathology rates: Initial consultation to meet client, Screening, Assessment, Intervention, Consultation with family, school or team members, Therapy preparation, Documenting sessions, Participation in team meetings, Goal plan writing and updating, Writing reports and treatment summaries, Training aides, Completing forms, Preparing a home program, Telephone consultation of 15 minutes or more in length. *

I understand the details of my investment and I understand that all of the services listed are billable.

Family participation

The client may be asked to complete activities and/or carry out strategies and recommendations outside of the treatment sessions. Assistance from family members/parents/guardians/friends will support the client's progress and they are welcome to attend the sessions. *

I understand that family participation is encouraged.

Teletherapy & Digital security and confidentiality

I understand that teletherapy includes the use of interactive audio, video or and data communication. I understand the risks associated with teletherapy which can include technical difficulties, transmission of information may be disrupted or distorted, information could be interrupted or accessed by unauthorized persons. I understand the benefits associated with teletherapy can include but are not limited to the following: the client has access to therapy from anywhere in Alberta, may increase regularity and consistency, and can help the client achieve goals and outcomes. I understand that email transmissions, completed forms and all of the therapist's documentation are stored online through a platform that complies with the Protected Health Information privacy rules. I understand that safeguards have been established to protect privacy and confidentiality but no technological communication system is entirely secure. *

I understand the risks associated with digital communication and storage and consent to teletherapy services (if applicable)

Full Name *

By writing your name you agree all statements are true and agree to a binding contract.