Intake Form Private/Group Therapy
Thank you for completing this information prior to evaluation and/or therapy sessions begin. Rainbow Tree Therapies, LLC is providing private therapy in one one one and small group sessions. Small group sessions occur when the fit is appropriate and there is a peer group to access. Animals may be used in therapy but consistently apart of therapy. There may be interactions with animals but we currently do not provide therapeutic horse riding as part of therapeutic services. Horse riding is consistently available during our Find Your Rhythm Camp during the Summer months and for occasional retreats offered in the Fall season.
Email address *
Child's Name *
Your answer
Child's Date of Birth *
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Parent or Caregiver (s) Name *
Your answer
Parent/Caregiver Street Address *
Your answer
Parent/Caregiver Main Phone Contact Number *
Your answer
Emergency Contact Name and Number (can be the same as above) *
Your answer
What is Today's Date: *
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This form is for private or small group therapy. Please check that in which you are interested in receiving: *
Required
Does your child have a diagnosis? If so, what is the diagnosis and who provided the diagnosis?
Your answer
Significant Prenatal History:
Your answer
Labor & Delivery (check any that apply) *
Required
Comments Regarding Labor & Delivery
Your answer
Infancy & Toddlerhood *
Required
Comments About Infancy & Toddlerhood
Your answer
Age your child crawled?
Your answer
Age your child walked?
Your answer
Age your child spoke first word?
Your answer
Is your child toilet trained
SCHOOL-AGE (Check all that apply)
Comments Regarding School Functioning
Your answer
Please check all that applay to your child currently.
If you checked any of the above boxes, please include comments including medication name if prescribed and currently taking, how many meltdowns in a day and any additional comments regarding above.
Your answer
Check what if any services your child currently receives or has received in the past.
Please list your child's strengths and interests.
Your answer
Please list your specific concerns regarding your child's development and challenges within the daily routine.
Your answer
Please include any medical conditions that your child is managing or has in the past.
Your answer
May we email you to communicate with you regarding your child? *
Please check regarding Evaluation at Rainbow Tree Therapies, LLC *
Required
Payment/Invoice
Rainbow Tree is a cash based business model. Payment for the evaluation will be collected the day of the evaluation. If your child requires direct therapy services, an invoice will be sent to you for an up front payment of 4 sessions. This payment will be made prior to any services provided. It is likely that your child may require at least 12 total sessions. Fee per session is $80. After 4 sessions, you and your providing therapist can discuss continued need or plan for therapy.
Payment Agreement *
Superbill - A superbill is a document provided after payment that could be submitted to insurance for POSSIBLE reimbursement. You are responsible for submitting to insurance.
By checking each of the the following, you are agreeing with the statements in their totality. *
Required
RELEASE/HOLD HARMLESS/AUTHORIZATION OF MEDICAL TREATMENT
The following will seek your permission for release of information and for permission for Occupational Therapy graduate students to observe and/or be apart of therapy.
I authorize the therapists at Rainbow Tree Therapies LLC to allow my child to occasionally be observed during therapy sessions by fieldwork students/interns and/or volunteers. I understand that these individuals will be signing confidentiality agreements. This agreement remains in affect until your child has been officially discharged from therapy. *
I agree to the above. Add Your Name & Date you agreed. *
Your answer
Release of Information (read below)
Information to be released would include evaluation information and goals.
I authorize Rainbow Tree Therapies to release information to, obtain information from and exchange information with the following listed private therapy clinic, school personnel, or physician that you would like us to consult with to provide comprehensive or collaborative support regarding your child. ****By listing the names and contact number, you are authorizing this release. If not authorizing anyone, please indicate "NO AUTHORIZATION." This authorization will be in affect until your child has been discharged from therapy at Rainbow Tree Therapies and updated as needed. *
Your answer
I agree to the above and I understand that I have the right to refuse to sign this form and I may revoke my consent in writing at any time (except to the extent that the information has already been released). Add your Name & Date you agreed. *
Your answer
Release Of Liability/Hold Harmless/Photo Release/Medical Authorization. PLEASE CHECK ALL THAT MAY APPLY. *
Required
Provide your Name & Date to which you agreed to above. *
Your answer
CONTACT INFORMATION FOR RAINBOW TREE:
Rainbow Tree Therapies, LLC
477 Perch Lake Rd
Hudson, WI 54016
Phone: 715-205-2703
Email: lhaverly@rainbowtreetherapies.com
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