Starfish Therapies

A pediatric therapy company operating in San Francisco and the greater Bay Area. We provide physical, occupational, speech and aquatic therapy services in the most beneficial and convenient setting for you and your child, including our clinic, currently located in Burlingame, your home, school or daycare.

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Motor Smart Kids Intake Form

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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*
Sex*
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*
- 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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CANCELLATION/NO SHOW POLICY*
As 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.” Every fifth less than 24-hour cancellation will result in a full session charge.
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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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES*
VIEW & DOWNLOAD NOTICE OF PRIVACY PRACTICES HERE

The privacy of your protected health information is important to us. We have provided you with a copy of our Notice of Privacy Practices. It describes how your health information will be handled in various situations. Please sign this form to acknowledge you received a copy of our Notice of Privacy Practices.

If your first date of service with us was due to an emergency, we will try to give you this Notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.

By signing below, I acknowledge that I have received Starfish Therapies’ Notice of Privacy Practices:
Signature*
Date*
MM slash DD slash YYYY
Please tell us how you heard about us:*
Phone
This field is for validation purposes and should be left unchanged.

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Motor Smart Kids
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What Clients Are Saying

We are grateful for all of the time/effort/sweat Stacy puts in for our son!
“We have been so happy with our experience with Stacy. She is a skilled therapist who is so open to all of our questions and ideas. We have worked with a number of different therapists over time, and Stacy has truly been the best therapist for our son! We have also done physical therapy intensives with different clinics across the country, and found our intensive with Starfish to be the most useful and most tailored to what our son needs (not just a cookie cutter formula). We are grateful for all of the time/effort/sweat Stacy puts in for our son!”

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Contact

(650) 638-9142
(650) 638-9141
admin@starfishtherapies.com

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Location

BURLINGAME
1541 Old Bayshore Highway
Burlingame, CA 94010

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