To get started, fill out some general information. This should take around 10 minutes.

Name

Email Address

Type of Services (check all that apply) Type of Services (check all that apply) Speech Therapy (available in PA & WV) Physical Therapy (available in PA) Orofacial Myofunctional Therapy (not available at this time) Occupational Therapy (not avaliable at this time)

Patient's Full Name

Patient's Date of Birth (mm/dd/yyyy)

Patient's Gender Patient's GenderMaleFemale

Phone Number

Complete Address (Street, City, State, Zip Code)

Emergency Contact Name

Emergency Contact Phone Number

Reasons for Seeking Therapy (Ex. speech delay, stuttering, articulation, pronunciation, difficulty swallowing, rehabilitation, etc.)

Preferred Contact Method Preferred Contact MethodCallTextEmail

Language(s) Spoken at Home (Primary & Secondary)

Patient's Verbal Ability Patient's Verbal AbilityVerbalNon-verbal

Preferred Service Location Preferred Service LocationVirualIn-person

How did you hear about us? (Please be as specific as possible!!)

Primary Care Physician/Pediatrician's Name

Primary Care Physician/Pediatrician's Phone Number

Available Appointment Schedule (list both days and times of day)

Medical history - list any known diagnosis or medical issues including date of onset

Medications and any known allergies

Check if the client has any of the following illnesses: Check if the client has any of the following illnesses: Ashtma Cancer Developmental Delay Diabetes Ear Infection Fractures Hearing Loss/Deafness Heart Disease Hypertension (high blood pressure) Kidney Disease Seizure Disorder Thyroid disease/Lupus/Autoimmune Disease Tuberculosis Other genetic conditions/diseases None of the above

Past hospitalizations and/or surgeries if any

Please send us a picture of your insurance card(s) (front & back) and copy of referral (ST/OT/PT Order) by emailing it to televine@televinetherapy.com or via fax to 330-649-2001 so we can request an approval from your insurance. **If you have more than 1 active insurance policy, make sure to also provide your Secondary insurance details for Coordination of Benefits otherwise, we will only coordinate with your Primary insurance.

Primary Insurance Company

Insurance ID Number

Insurance Group Number or N/A

Employer

Insurer's Full Name

Insurer's Date of Birth (mm/dd/yyyy)

Secondary Insurance Company (if applicable)

Secondary Insurance ID Number

Secondary Insurance Group Number or N/A

Secondary Insurer's Employer

Secondary Insurer's Full Name

Secondary Insurer's Date of Birth (mm/dd/yyyy)

We would love to capture our client's achievements in photo/video form and consent is warranted to do so. We are looking forward to sharing patient's stories by picture and video to celebrate the time we spend together. The Photo and Video Release Form must be signed due to Ohio, Pennsylvania, & West Virginia Law. If you have any questions about this form, send us an email at Televine@televinetherapy.com or call (330)536-3042 or (570)360-8646.

I hereby allow Tara Helwig Enterprises LLC, TeleVine Therapy and its affiliates to record and publish photos and videos (including audio) of me/my minor child or ward for the purpose of promoting TeleVine Therapy and for documenting and/or reporting events and activities. I understand that this media will be produced and used for promotional purposes, and I authorize TeleVine Therapy to use mine/my child’s or ward’s photograph, video, and/or audio recording on its website and social media platforms, such as Facebook, Twitter, YouTube, etc., as well as other official printed publications without further consideration. I also understand that once mine/my child’s or ward’s image(s) have been captured, that his/her image(s) may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein his/her likeness appears. Additionally, I waive any right to any compensation arising from or related to the use of his/her image or recording. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for any authorized purposes.

Accept/Decline Accept/DeclineAcceptDecline

Electronic Signature

Date Completed