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Background Information and Occupational Intake – Adult

WELCOME TO DV THERAPY
We are pleased to provide your therapeutic services. It is our goal to provide the most effective and family-centered treatment as possible. Comments regarding your experience with our practice are always welcome. This information helps us meet your individual needs and maintain quality services for our clients.
CLIENT SERVICE AGREEMENTS We have found that clarity at the beginning of a clinical relationship fosters a good working partnership. In order to prevent confusion or misunderstanding regarding our policies and procedures, READ AND RETAIN the following information for your reference.
Family involvement: We highly encourage parents to be an active participant during the sessions. During or at the end of the sessions, parents/caregivers will be instructed on how to carry over lessons, implement homework, and activities throughout the week. Parent training/coaching will be provided for tips and insights. Parents are required to complete home program activities.
Discharge planning: The exit criteria for discharge may be due to one of the following reasons: poor attendance, reached age appropriate function, progress with therapy has plateaued, not able to participate in skilled therapy due to lack of attention/behavior, or due to parent’s request. In the event that a client has to be discharged due to noncompliance with treatment recommendations, the plans will be discussed with the clinician and the family/legal guardian.
Behavioral health: Our clinician’s safety is very important. If the client presents with inappropriate behaviors that interfere with the therapy and puts the clinicians in any danger, services may be placed on hold or terminated until a plan of action is proposed with the parent, office manager, and/or the supervisor.
Supportive community services: Our therapists will provide family members with supportive community services that may benefit the client.
Right to refuse services: DV Therapy Inc respects and protects their staff members against any aggression made toward staff whether verbally or physically. As such services will immediately stop for a client, if our staff is disrespected by the client, caregivers, or guardians.
HOW TO CONTACT US:
You may reach the office by calling twenty-four hours a day. Our administrative hours are Monday - Friday, 9 am - 5pm. If there is no one available to answer your phone call, please leave a message and we will return your call promptly. Any call after administrative hours will be returned the following day.
Main office number: 323-426-6402 Email: [email protected]
OUR SERVICES AND FEES
The client is responsible for all payments due at the time of service.
We are in network with a number of insurance companies and government sponsored programs. For any insurance that DV Therapy is ‘in network’ with, we will bill the insurance company directly. Please note that if your deductible has not been met, you will be responsible for the full amount at time of service. If there is a denial from the insurance, you will be responsible for the full payment once we receive the denial.
For all others, we will bill the client directly, giving the family the opportunity to work with their own insurance companies to seek reimbursement. We will provide the client with receipts and invoices, which will list diagnosis and procedure codes as required by insurance companies.
We highly recommend that all families check with their insurance companies to review coverage details before agreeing to begin therapy with us
We accept the following forms of payment:
-Checks made out to “DV Therapy” - Cash -Credit Cards
DV Therapy Client Service Agreement- 2020 2
Thirty days notice will be given in advance of any fee increases for treatment services.
COMPREHENSIVE INITIAL EVALUATION
Evaluation sessions last 1-1.5 hours.
OT rates
Therapy: $130 for 30 mins
Therapy: $260 for 60 mins
Evaluation: $90 for every 15 minutes

ST rates
Therapy: $75 for 30 mins
Therapy: $150 60 mins
Evaluation: $300 hr

Evaluations include some or all of the following depending on the age and needs of each child:
● Standardized Articulation Assessment
● Oral Motor/Feeding Evaluation
● Phonological Processes Inventory
● Vocabulary Inventory
● Reading Fluency Assessment
● Reading Comprehension Assessment
● Stuttering/Fluency Assessment
● Social Skills Evaluation and Observation
● Parent Questionnaire/Developmental History
● Parent/Teacher Interview
When DV Therapy has not conducted the speech-language evaluation for your child, we REQUIRE that you provide us with a copy of the outside evaluation report, completed within the last six months, before we can begin treatment. We cannot ethically begin therapy without an evaluation.
TREATMENT SESSIONS
Sessions are carefully pre-planned for your child. Your child will work directly with the therapist for the bulk of the session, leaving 10 minutes at the end to talk with the parent and/or write a brief treatment note. Please be considerate of the therapist's schedule as he/she may have another session following yours. If you require an extended conversation with your speech therapist, you may schedule a time for a meeting or phone conference.
Carry-over of treatment goals and progress into your child’s natural environment and routine is critical for maximum progress. For parents who are not able to participate in sessions, a communication plan should be determined directly with the therapist at the start of treatment and modified as needed during the course of treatment. Options include email, notebooks, multi-media messaging, and/or meetings.
When observing/participating in a treatment session, we would appreciate your consideration in the following:
• Please minimize the amount of distractions during the sessions
• Please be considerate of time constraints by keeping post session conversations short.

TREATMENT RATES
Session lengths may vary from 30 minutes to 2 hours depending on each individual situation, so charges are based on the set rate; $75 30 minutes and $125 for an hour.
Group sessions are billed according to the length of session and number in the group.
Periodically it is necessary to participate in extensive case management activities, such as parent and school conferences, to assure proper coordination of and communication about services. Therefore, with parental notification, conferences with parents, teachers, and other professionals, school observations, and lengthy telephone consultations will be billed at the hourly rate. There is no additional charge for “routine” case management activities (planning, chart keeping, brief coordination calls). Supplementary testing and/or re-evaluations, conducted with parental permission, will be billed at the evaluation rate of $225.
REPORT FEES
Additional reports (other than Annual Treatment Summaries and/or Discharge Reports, which are written by the SLP) will be billed at the hourly rate. When you or your insurance company REQUEST ADDITIONAL REPORTS, you will be billed at the hourly rate.
RELEASES OF INFORMATION
We respect your confidentiality in all matters. If you would like us to release information about an evaluation and/or treatment to another agency or professional, please request our standard Release Form from the office. If you would like us to have prior records of your child, which are often very helpful clinically, please have the information forwarded to our office.
RECORD KEEPING
DV Therapy Speech Services keeps copies of evaluations, re-evaluations, session notes, and discharge reports for all clients. We provide clients with copies of all formal reports upon request. It is our policy to keep digital office copies of these formal reports for a period of 5 years after client discharge. After that time, the records will be removed from our database. You are encouraged to keep and store your own copies of formal reports for your permanent records.

CONSENT TO TREATMENT


I consent to the following treatment as ordered by my physician and outlined in the treatment plan of care. I understand the risks and benefits of the treatment and I understand that I can ask questions to the treating clinician at any time regarding the treatment.

Background Information

Client full name(Required)
Is your primary language spoken English?
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
If yes, please provide language needed(Required)
No, I would like to opt out of interpreter services
Client's Name(Required)
MM slash DD slash YYYY
Age(Required)
Address(Required)

    Background Information



    YesNo


    YesNo


    YesNo

    Referring Information

    Medical History


    PsychologistPTSpeech and LanguageNutritionistBehavioral SpecialistOther:

    * - Please note frequency/duration of services (e.g. PT 1x/week for 60 minutes)

    Self-Care Skills

    Please check the box that most accurately reflects the amount of assistance needed for the client to complete the following:


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)

    Range of Motion (ROM) / Pain Levels

    For the “Pain Level” columns, please write a number between 0-10 (0 = no pain, 10 = max pain).

    For the range/motion columns, please check one of the three boxes that most accurately reflects your current range of motion in the following areas:

    BodyPart & Movement

    Pain Level – at rest

    (0-10)

    0 = no pain

    10 = max pain

    Pain Level – at max range

    (0-10)

    0 = no pain

    10 = max pain

    Range/Motion

    Neck - looking left and right

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Neck - looking up and down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Neck - tilting head to touch shoulder

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Shoulder – lifting arm straight in front, up towards ceiling

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Shoulder – lifting arm to the side (like a butterfly), up towards ceiling

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Elbow – bending

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Forearm – turning to palm up

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Forearm – turning to palm down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Wrist – moving left and right

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Wrist – moving up and down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Thumb – touching pinky

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Thumb – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Pointer finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Middle finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Ring finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Pinky finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Sensory Processing Checklist

    The purpose of this sensory processing checklist is to help you become educated/aware about particular signs of sensory processing dysfunction and allows the professional to gather a background of behavior responses. It is not to be used as a diagnostic criteria for labeling any sensory processing disorder; but rather, as an educational tool and checklist for knowledge. Please check symptoms that you feel best describe your current sensory behaviors/patterns.

    Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.

    Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.

    Vestibular Sense: The vestibular system is the sensory system that responds to motion or change of head position. The receptors for movement are located in the inner ear. They tell the brain what direction the head is moving, the speed of the movement and where we are in space.

    Other Senses: There are also sensory processing skills related to the visual (sight), auditory (sounds), oral (mouth, taste), olfactory (smell), and interoceptive (inner control, such as bladder & bowel, self-regulation).


    5 star ratingI love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing... read more
    Bianca C. Avatar
    Bianca C.
    10 months ago
    My 2 year old son has been improving so much over the last few months & im very thankful for... read more
    Stephanie De Cosse Avatar
    Stephanie D.
    1 year ago
    Im beyond happy with the services my daughter is receiving. Her therapist Lupe has done an amazing job, from keeping... read more
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    Ness M.
    1 year ago
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