Intake Form

Step 1 of 6

Today's Date*

MM slash DD slash YYYY
Child's First Name*
Child's Last Name*
Child's Date of Birth*

MM slash DD slash YYYY
Age*
Gender*
Language Spoken*
Ethnicity*
Home Address*

Street Address

Address Line 2

City

State

ZIP Code
Additional Address (if applicable)

Street Address

Address Line 2

City

State

ZIP Code
Parent / Guardian #1
First Name*
Last Name*
Relationship to Child*
Home Phone*
Cell Phone
Work Phone
Fax Number
Email*
Newsletter
- I do not wish to be added to the newsletter mailing list
Preferred Method of Contact*
- Phone
- Text
- Email
Parent / Guardian #2
First Name
Last Name
Relationship to Child
Home Phone
Cell Phone
Work Phone
Fax Number
Email
- I do not wish to be added to the newsletter mailing list
Preferred Method of Contact
- Phone
- Text
- Email

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Emergency Information
Emergency Contact First Name*
Emergency Contact Last Name*
Relationship to Child*
Phone*
Medical and Health Information
Pediatrician First Name*
Pediatrician Last Name*
Address*

Street Address

Address Line 2

City

State

ZIP Code
Phone*
Referring Physician Name (if different from above):
Referring Physician Address

Street Address

Address Line 2

City

State

ZIP Code
Phone
Diagnosis*

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Billing/Financial Information*

*Please present your insurance card to your therapist, along with any prescriptions for treatment at your initial visit. Please note, that as a courtesy to our patients, Starfish Thåerapies will check on the details of an individual’s benefits. Ultimately, Starfish Therapies is not responsible for and does not guarantee the accuracy of this information and therefore we advise all of our patients to always verify their personal coverage. The telephone number for your insurance company is usually on the reverse side of your identification card or on your benefit policy.

We will submit bills monthly to your insurance company. However, the financial responsibility for payment remains with you. Balances not received within 30 days of date on invoice will be assessed a $15 late charge and will accrue a 2% interest thereafter for every 30 days the outstanding balance goes unpaid, with the minimum amount of $1 interest charged. In the event that payment is not received within 30 days of the date on the invoice, Starfish Therapies reserves the right to suspend services until account is up to date.

Your insurance may cover all or a portion of your charges. You may be required to make a co-payment or fulfill your deductible to satisfy your bill. Co-payments and deductibles are due at the time of service.

All invoices are due upon receipt.

All charges quoted are estimates only and may not reflect your final bill.

If at any time your insurance deems a service ‘non-medically necessary’ and does not provide reimbursement for that service you will be given written notification. You will be given the option of continuing on with services or terminating services. If you choose to continue on with services you will be financially responsible for those services at the contracted insurance rate. The decision to continue services must be provided in writing to admin@starfishtherapies.com prior to services being resumed.

By initialing below I acknowledge I have read the above statements:

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CANCELLATION/NO SHOW POLICY*

AAs a courtesy to our therapists and our patients, please be sure to give at least 24-hours notice in the case that you are not able to make it to your scheduled appointment. In the event of a “no show” our patients will be billed 100% of the original charge. A less than one hour cancellation will be considered a “no show.” Missing part of your scheduled time due to late arrival or early departure (8 minutes or more) constitutes a partial no show and has associated fees commensurate with the time missed. Every fifth less than 24-hour cancellation will result in a full session charge.

By initialing below I acknowledge I have read the above statements:
TRAVEL COSTS*

A mileage fee will be added to your treatment costs for patients who require in-home therapy based on round trip mileage from the Burlingame clinic to the patient’s home (or place of therapy). The mileage fee will reflect the IRS Standard Mileage Rates. As the IRS increases or decreases the rates, our rates will adjust accordingly. There is a $5 minimum fee per treatment session. The fee cannot be submitted to your insurance carrier, so the patient/guardian will be responsible for the total charges for miles traveled.
Thank you for your cooperation.

By initialing below I acknowledge I have read the above statements:
PHOTO/VIDEO RELEASE*
I authorize the use of videos/photos for the following (please check):
- Personal Use (i.e. home exercise programs, charting progress, etc.)
- Marketing Purposes (i.e. Web content, advertising, illustration, etc.) I grant to Starfish Therapies, its representatives and employees the right to take photographs of me and/or my child and my property in connection with the above identified subject. I authorize Starfish Therapies, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Starfish Therapies may use such photographs of me and/or my child with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, Web content and therapist usage.
- No Photos/Videos
Initials*
Form NTC 12-01*

VIEW & DOWNLOAD Form NTC 12-01 HERE

I acknowledge that Starfish Therapies has provided with a copy of Form NTC 12-01.

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Intake Form

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