For Office Use Only

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2019-2020 Update Infromation

2019-2020 Annual Evaluation Update

 

This will be used for all existing clients who do not have an entry in this form currently. Please complete the parents email and select the clincina of record before hitting save. Once saved,  select “Share Entry” and select the confirmation email titled "2019-2020(Action Required) Annual Evaluation at Speech Pathway" and follow the list in basecamp.

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Intake Form

 

Intake Form (New Client)

 

When an intake form is completed online the guardians will receive an automatic email confirming their submission and a generic email with the next steps. Once you have reviewed the intake form and determined that all the pertinent information is completed a follow-up email will be activated when you answer the following questions and click UPDATE. **an email will be sent if you answer yes to any of the questions and click the green “UPDATE” button at the bottom of the form.

  • If “Question 1” = Yes and “Question 2” = No and “Question 3” = No,  a confirmation email will be sent WITHOUT the “Soonercare: Change of Provider” form attached.
  • If “Question 1” = Yes and “Question 2” = Yes and “Question 3” = No,  a confirmation email will be sent WITH the “Soonercare: Parental Consent Form” attached.
  • If “Question 1” = Yes and “Question 2” = Yes and “Question 3” = Yes,  a confirmation email will be sent WITH the “Soonercare: Change of Provider” form attached and the “Soonercare: Parental Consent Form.” attached.
  • If “Question 1” = No and “Question 2” = No and “Question 3” = No,  No email will be sent to the guardian.

If the form is NOT COMPLETE, select the “SHARE” button at the top of this form. By default, the guardian email will be inputted into the “TO” portion of the email. Feel free to edit the “SUBJECT” and “MESSAGE” portion and then click the green “SEND” button to send the parent an email to complete the form. *Note: Once you send this email the clients intake form will be marked as “incomplete” leave this incomplete and it will go back to “completed” once they have filled out the requested information for review again. 

1. Are all required/needed fields completed on this clients intake form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If no, nothing will happen. When “Yes” is selected and you click the green “update” button a “Getting Started at Speech Pathway!” confirmation email will be sent. Make sure the form is completed before selecting “Yes”.

 

2. Does the child utilize soonercare as either a primary, secondary, or tertiary? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Selecting this button will send a different “Getting Started at Speech Pathway!” confirmation email which will include a link to complete the “Soonercare: Parental Consent Form.” You must also select “Yes” to the question “Are all required/needed fields completed on this clients intake form?” to send this email.

 

3. Does this parent need to complete a change of provider form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Selecting this button will send a different “Getting Started at Speech Pathway!” confirmation email which will include a link to complete the “Soonercare: Parental Consent Form.” and a link to complete the “Soonercare: Change of Provider”. You must also select “Yes” to the question “Are all required/needed fields completed on this clients intake form?” to send this email.

 

Scheduling Evaluation

 

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Do we have a referral? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Approximate Length of Evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Scheduling Consultation

 

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Annual Evaluation

 

Annual Evaluation

 

This will be used for all existing clients who already have an entry in this form. Please complete the below fields. Further, please review that the insurance information on file is correct prior to saving this document. Once saved,  select “Share Entry” and select the confirmation email titled "(Action Required) Annual Evaluation at Speech Pathway" and follow the list in basecamp. 

*** If this is the second (or more)  time this child is going through the annual evaluation process, you will need to uncheck the attests at the bottom of each page and delete the signatures on the last three pages before sending ***



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Insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Annual Evaluation has been reveiwed by FoH {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Annual Evaluation

 

Please review your child’s information on this form. For your convenience the information has been pre populated. Please take your time reviewing the information. There is an option at the bottom of the page to update information with any changes. By answering yes to the question “ I need to update the information above.” the fields will become active and you will be able to edit them. Once you have edited the information you will be asked to attest that the information is accurate.

Annual Evaluation & System Update

 

It is time for your child’s annual evaluation. Speech Pathway has recently updated their systems and we are asking all families to update their intake paperwork for our office. Thank you in advance for taking the time to complete this information for us. *Before you begin please have copies/pictures of the front and back of your insurance cards as well as any reports from other professionals you would like to include.

Name of person completing this form {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Child's (Legal) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Child's (Legal) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Child's Preferred Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guardian(s) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guardian(s) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is this an Emergency Contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship to Child {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guardian(s) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guardian(s) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is this an Emergency Contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship to Child {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship to Child {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Payment & Benefits Information

I am interested in... {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you are unsure about your benefits and would like Speech Pathway to help discover what will work for your family please select “Unsure/Both?”

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Please contact our office if this is not correct.

Do you have more than one insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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i.e. Medicaid, Soonercare, etc.

I have a secondary insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have a third insruance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The individual or firm (usually the policyholder) with whom the insurance contract is made, and whose interests are protected under the policy.

Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Specifically named individual or firm (usually the policyholder) with whom an insurance contract is made, and whose interests are protected under the policy. In some cases, more than one entity may be designated as named insureds.

Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

FRONT of Insurance Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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BACK of Insurance Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Secondary Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Specifically named individual or firm (usually the policyholder) with whom an insurance contract is made, and whose interests are protected under the policy. In some cases, more than one entity may be designated as named insureds.

Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Specifically named individual or firm (usually the policyholder) with whom an insurance contract is made, and whose interests are protected under the policy. In some cases, more than one entity may be designated as named insureds.

Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

Copy of Insurance Card - Front {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
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Copy of Insurance Card - Back {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Third Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Specifically named individual or firm (usually the policyholder) with whom an insurance contract is made, and whose interests are protected under the policy. In some cases, more than one entity may be designated as named insureds.

Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Specifically named individual or firm (usually the policyholder) with whom an insurance contract is made, and whose interests are protected under the policy. In some cases, more than one entity may be designated as named insureds.

Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

Copy of Insurance Card - Front {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
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Copy of Insurance Card - Back {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
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I need to update the information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{# pageNumbers}

Speech-Language History 

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How would you classify their speech-language problem? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do the parents feel the child stutters or stammers? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe your child's voice. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the primary way your child communicates wants and needs at this time? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gestures include: nodding yes/no, pointing to desired objects, reaching out, etc.

Has your child ever been evaluated by any speech or hearing specialist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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SLP/AUD Report

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Medical History

Prenatal and Birth History

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Type of delivery: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Illnesses, Injuries or Operations (on the child)

Check any illnesses that apply {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hearing

Is there any reason to believe that he/she might have a hearing problem? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child's hearing ever been tested? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did your child pass their newborn hearing screening? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child’s hearing been screened/tested within the last year? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hearing Examination Results

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Person who completed the evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Normal results, Mild hearing loss, referred to... etc.

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Hearing Examination Results

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Person who completed the evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Normal results, Mild hearing loss, referred to... etc.

{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
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Does your child wear a hearing aid or amplification device? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Vision

Has the child's eyes been examined? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been concerned with your child's vision? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has he/she ever worn glasses/contacts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Allergies

Does the child have any allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Allergy List

Allergy {binding ItemNumber}
Allergic to {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Reaction/ Treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the Allergy information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medications

Does the child take any daily medications? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medications List

Please list all medications the child is currently taking

Name
Dosage
How long?
Reason
Medication {binding ItemNumber}
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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How long? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Reason {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the medication information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis

Has your child been diagnosed with any of the following conditions? (select all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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MedicalDiagnosisQ2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis Results / Report

Report {binding ItemNumber}
Please describe when and by whom {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis Report {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
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{binding Description}
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If your child has been diagnosed by a professional please attach the professional's recommendations, or diagnostic testing results.

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I need to update the medical diagnosis information above or upload a file. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{# pageNumbers}

Educational Status

Does he/she attend school? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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School Information

Name of Child's School {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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School District {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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What Grade? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child had to repeat a grade? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please describe any special services your child receives at school (reading, speech, etc.). {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If your child receives Special Education Services please provide us with a copy of your child's most recent IEP.

School IEP Upload {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{binding Name, mode=oneTime}
{binding Description}
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Please upload the most recent copy of your childs IEP

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I need to update the education information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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{# pageNumbers}

Developmental & Family History

Developmental History

Provide the approximate age at which the child began to do the following activities:

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Family History

Who are the primary care takers of the child? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(More than 14 hours a week) Select all that apply

What is your family structure? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are there any special custody or living arrangements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
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Is the child adopted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Behavior at Home

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i.e. energetic, passive, quiet, loud, etc.

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i.e. inflexible, sensitivity to noise, rigid routine

Does the child have any close friends? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the child play actively with other children? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the child care for themself (dressing, eating, etc.) like other children their age? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Parent Review

Parent Review 


Part of what makes Speech Pathway so special is the collaboration we have between clinicians, parents, and patients.  In order for us to continue to serve you to the best of our abilities, please take the time to answer a few questions. Your responses will not be shared with your child’s clinician. These are reviewed by administration staff and are used to grow Speech Pathway.

 

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Scheduling & Office Information

Help us make your family's experience at Speech Pathway better. Please provide us with a list of favorite things such as TV/ Movie characters, Games, Toys, Color, Things that are motivating and anything else that will allow us to get to know your child and have activities that they enjoy ready for their visit to Speech Pathway. Additionally, We ask you to provide information regarding scheduling. We do our best to accommodate your family’s schedule and the more flexible you can be the more flexible we can be!

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Do you have to have evening appointments (after 4:00p.m.)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you able to attend weekly sessions between 9a.m.- 4p.m.? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you would like to add the person(s) name who got you in contact with us, select other and type in the person(s) name.

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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Photo and Video Release Agreement

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YesNo
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I need to update my Photo and Video Release Agreement answers. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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By signing this document, I hereby waive any rights of compensation or ownership thereto of all photos/videos. Further, by signing below I understand that the office of Speech Pathway LLC. records video surveillance to ensure the safety of our staff, families, and patients.

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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Please include all professionals you wish Speech Pathway to have contact and/or coordination of care with. To speak with your child’s ENT, Psychician, School Based Speech Language Pathologist, Psychologist, or other Therapists we will need them added to the Medical Release Form.

Medical Release Form

Pediatrician Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pediatrician's Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Additional Professionals and/or Agencies

This would include your child's ENT, Neurologist, School SLP, etc. Person(s) listed will be allowed to collborate on your child's care.

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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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In consideration of treatment and education purposes, I give consent that sound recording, record, and/or photographs may be used as deemed helpful by Speech Pathway. This form has been fully explained to me/us and I/we understand the contents.

By signing below, I agree and consent to allow Speech Pathway LLC. to release information to the person(s) listed on this form. 

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Witness Signature

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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Terms and Conditions

Speech Pathway is committed to providing quality services. Prior to your evaluation please review our Terms and Conditions. All members participating in speech language services must agree to these Terms and Conditions. They can be found at https://speechpathway.net/terms-conditions/.

 

Policies and Procedures

Speech Pathway is committed to providing every child with medically necessary Speech-Language services. Prior to beginning services all parents will be provided and asked to sign a copy of our Policies and Procedures. Our Policies and Procedures are available on our website at www.speechpathway.net.

By signing below, I hereby authorize Emily Hathaway and associates at Speech Pathway to evaluate, as well as provide any subsequent treatment based on the evaluation results for Speech Therapy for child names on this form.  I certify that I am a legal guardian and have authority to give consent for medical services. In addition, by signing below I have read and agree to the Terms and Conditions as well as the Policies and Procedures of Speech Pathway.

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The email has been sent.

Your progress has been saved.

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For Office Use Only

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2019-2020 Update Infromation

2019-2020 Annual Evaluation Update

 

This will be used for all existing clients who do not have an entry in this form currently. Please complete the parents email and select the clincina of record before hitting save. Once saved,  select “Share Entry” and select the confirmation email titled "2019-2020(Action Required) Annual Evaluation at Speech Pathway" and follow the list in basecamp.

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Intake Form

 

Intake Form (New Client)

 

When an intake form is completed online the guardians will receive an automatic email confirming their submission and a generic email with the next steps. Once you have reviewed the intake form and determined that all the pertinent information is completed a follow-up email will be activated when you answer the following questions and click UPDATE. **an email will be sent if you answer yes to any of the questions and click the green “UPDATE” button at the bottom of the form.

  • If “Question 1” = Yes and “Question 2” = No and “Question 3” = No,  a confirmation email will be sent WITHOUT the “Soonercare: Change of Provider” form attached.
  • If “Question 1” = Yes and “Question 2” = Yes and “Question 3” = No,  a confirmation email will be sent WITH the “Soonercare: Parental Consent Form” attached.
  • If “Question 1” = Yes and “Question 2” = Yes and “Question 3” = Yes,  a confirmation email will be sent WITH the “Soonercare: Change of Provider” form attached and the “Soonercare: Parental Consent Form.” attached.
  • If “Question 1” = No and “Question 2” = No and “Question 3” = No,  No email will be sent to the guardian.

If the form is NOT COMPLETE, select the “SHARE” button at the top of this form. By default, the guardian email will be inputted into the “TO” portion of the email. Feel free to edit the “SUBJECT” and “MESSAGE” portion and then click the green “SEND” button to send the parent an email to complete the form. *Note: Once you send this email the clients intake form will be marked as “incomplete” leave this incomplete and it will go back to “completed” once they have filled out the requested information for review again. 

1. Are all required/needed fields completed on this clients intake form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If no, nothing will happen. When “Yes” is selected and you click the green “update” button a “Getting Started at Speech Pathway!” confirmation email will be sent. Make sure the form is completed before selecting “Yes”.

 

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Selecting this button will send a different “Getting Started at Speech Pathway!” confirmation email which will include a link to complete the “Soonercare: Parental Consent Form.” You must also select “Yes” to the question “Are all required/needed fields completed on this clients intake form?” to send this email.

 

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Selecting this button will send a different “Getting Started at Speech Pathway!” confirmation email which will include a link to complete the “Soonercare: Parental Consent Form.” and a link to complete the “Soonercare: Change of Provider”. You must also select “Yes” to the question “Are all required/needed fields completed on this clients intake form?” to send this email.

 

Scheduling Evaluation

 

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Scheduling Consultation

 

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Annual Evaluation

 

Annual Evaluation

 

This will be used for all existing clients who already have an entry in this form. Please complete the below fields. Further, please review that the insurance information on file is correct prior to saving this document. Once saved,  select “Share Entry” and select the confirmation email titled "(Action Required) Annual Evaluation at Speech Pathway" and follow the list in basecamp. 

*** If this is the second (or more)  time this child is going through the annual evaluation process, you will need to uncheck the attests at the bottom of each page and delete the signatures on the last three pages before sending ***



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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Annual Evaluation

 

Please review your child’s information on this form. For your convenience the information has been pre populated. Please take your time reviewing the information. There is an option at the bottom of the page to update information with any changes. By answering yes to the question “ I need to update the information above.” the fields will become active and you will be able to edit them. Once you have edited the information you will be asked to attest that the information is accurate.

Annual Evaluation & System Update

 

It is time for your child’s annual evaluation. Speech Pathway has recently updated their systems and we are asking all families to update their intake paperwork for our office. Thank you in advance for taking the time to complete this information for us. *Before you begin please have copies/pictures of the front and back of your insurance cards as well as any reports from other professionals you would like to include.

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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Child's Preferred Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Months {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Guardian(s) Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship to Child {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email Other {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Payment & Benefits Information

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I understand that not providing all insurance information an/or withholding insurance information may impact reimbursement for services. All claims denied for services rendered will be billed to the individual named on this intake form. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have a secondary insurance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

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Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

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BACK of Insurance Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Secondary Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

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Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

Copy of Insurance Card - Front {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Copy of Insurance Card - Back {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
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Third Insurance Information

Please include all primary and secondary insurances. Failure to provide and/or withholding insurance information may delay services. All denied claims for services rendered will be billed to the individual named on this intake form. 

If you are using insurance benefits, it is required that a referral for speech therapy be on file from your child's primary care physician. 

Name on insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Card holder date of birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name of the patient (child) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Customer Service phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Upload a picture of the FRONT and BACK of your insurance card(s).  Keep pictures seperate.  If you don't have a physical card, write all the same information down on a piece of paper and upload a picture of it. 

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Copy of Insurance Card - Back {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have reviewed and attest that the information above is accurate at this time. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Speech-Language History 

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Is the child aware of the problem? If yes, how does he or she feel about it? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At what approximate age did your child begin to use single words like no, mom, dog, Jedi? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At what approximate age did your child combine words like me go, daddy shoe, light saber? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At what approximate age did your child name simple objects like tree, dog, car, Yoda? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At what approximate age did your child use simple questions like Where's doggie? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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At what approximate age did your child engage in conversation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Approximately what age was your child when you first became concerned about their speech? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How would you classify their speech-language problem? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do the parents feel the child stutters or stammers? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe your child's voice. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the primary way your child communicates wants and needs at this time? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child ever been evaluated by any speech or hearing specialist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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SLP/AUD Report

If yes, by who? When? Where? What were the results? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Previous evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical History

Prenatal and Birth History

Mother’s general health during pregnancy (illnesses, accidents, medications, etc.). {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Was the child premature? how early? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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General condition at birth: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birth weight: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Type of delivery: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Were there any unusual conditions that may have affected the pregnancy or birth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Illnesses, Injuries or Operations (on the child)

Check any illnesses that apply {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has the child had any surgeries? If yes, what type and when (e.g., tonsillectomy, tube placement)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child had any major surgeries and/or illnesses within the last year? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe any major accidents or hospitalizations. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hearing

Is there any reason to believe that he/she might have a hearing problem? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child's hearing ever been tested? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Did your child pass their newborn hearing screening? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Has your child’s hearing been screened/tested within the last year? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hearing Examination Results

Approximate date of last hearing screening/test {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Person who completed the evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Results {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please upload a copy of their results. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hearing Examination Results

Approximate date of last hearing screening/test {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Person who completed the evaluation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Results {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please upload a copy of their results. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
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Does your child wear a hearing aid or amplification device? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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If so, for how long? What kind? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Vision

Has the child's eyes been examined? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Have you ever been concerned with your child's vision? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Has he/she ever worn glasses/contacts? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Allergies

Does the child have any allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Allergy List

Allergy {binding ItemNumber}
Allergic to {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Reaction/ Treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the Allergy information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medications

Does the child take any daily medications? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medications List

Name
Dosage
How long?
Reason
Medication {binding ItemNumber}
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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How long? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Reason {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the medication information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis

Has your child been diagnosed with any of the following conditions? (select all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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MedicalDiagnosisQ2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis Results / Report

Report {binding ItemNumber}
Please describe when and by whom {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medical Diagnosis Report {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
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I need to update the medical diagnosis information above or upload a file. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have reviewed and attest that the information above is accurate at this time. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Educational Status

Does he/she attend school? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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School Information

Name of Child's School {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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School District {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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What Grade? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Has your child had to repeat a grade? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please describe any special services your child receives at school (reading, speech, etc.). {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

If your child receives Special Education Services please provide us with a copy of your child's most recent IEP.

School IEP Upload {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I need to update the education information above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have reviewed and attest that the information above is accurate at this time. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Developmental & Family History

Developmental History

Provide the approximate age at which the child began to do the following activities:

Crawl {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stand {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Walk {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Feed Self {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Dress Self {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Use toilet {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Does the child have difficulty walking, running, or participating in other activities that require small or large muscle coordination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are there or have there ever been any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing)? If yes, describe. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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Family History

Who are the primary care takers of the child? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your family structure? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are there any special custody or living arrangements? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Please describe the custody and living arrangement(s). {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please upload any court documents that may impact your child's medical rights that may impact speech language therapy. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
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Is the child adopted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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How old was he/she when adopted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Behavior at Home

Describe your child's behavior(s) at home. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe any behavior(s) which interfere with daily living or activities. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the child have any close friends? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Does the child play actively with other children? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Does the child care for themself (dressing, eating, etc.) like other children their age? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Parent Review

Parent Review 


Part of what makes Speech Pathway so special is the collaboration we have between clinicians, parents, and patients.  In order for us to continue to serve you to the best of our abilities, please take the time to answer a few questions. Your responses will not be shared with your child’s clinician. These are reviewed by administration staff and are used to grow Speech Pathway.

 

Tell us why your child looks forward to therapy. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Tell us one new thing that your child can do now that they couldn’t do before starting therapy. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What does your child enjoy about their clinician? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What is something that the clinician does well with your child? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Is there something you would like to see your clinician do differently? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Tell us something that you like about Speech Pathway? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How could our environment be more comfortable? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How can we improve our communication with parents? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please tell us what we could change or improve to make your experience with Speech Pathway more positive. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Scheduling & Office Information

Help us make your family's experience at Speech Pathway better. Please provide us with a list of favorite things such as TV/ Movie characters, Games, Toys, Color, Things that are motivating and anything else that will allow us to get to know your child and have activities that they enjoy ready for their visit to Speech Pathway. Additionally, We ask you to provide information regarding scheduling. We do our best to accommodate your family’s schedule and the more flexible you can be the more flexible we can be!

Please tell us some of your child's favorite interests and/or things. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please describe your ideal therapy schedule? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have to have evening appointments (after 4:00p.m.)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Are you able to attend weekly sessions between 9a.m.- 4p.m.? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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How far do you live from our office? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Photo and Video Release Agreement

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I need to update my Photo and Video Release Agreement answers. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I have read and understood the Photo & Video Release Agreement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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By signing this document, I hereby waive any rights of compensation or ownership thereto of all photos/videos. Further, by signing below I understand that the office of Speech Pathway LLC. records video surveillance to ensure the safety of our staff, families, and patients.

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gaurdian's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Please include all professionals you wish Speech Pathway to have contact and/or coordination of care with. To speak with your child’s ENT, Psychician, School Based Speech Language Pathologist, Psychologist, or other Therapists we will need them added to the Medical Release Form.

Medical Release Form

Pediatrician Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pediatrician's Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pediatrician Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pediatrician Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Additional Professionals and/or Agencies

Persons and/or Agencies {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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In consideration of treatment and education purposes, I give consent that sound recording, record, and/or photographs may be used as deemed helpful by Speech Pathway. This form has been fully explained to me/us and I/we understand the contents.

By signing below, I agree and consent to allow Speech Pathway LLC. to release information to the person(s) listed on this form. 

Guardian's Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Witness Signature

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Speech Pathway
Emily Hathaway, M.S. CCC-SLP & Associates
Certified, Licensed Speech-Language Pathologists
6905 NW 122nd Street OKC OK 73142
Phone: (405) 603-6622
Fax: (405) 722-3244

Terms and Conditions

Speech Pathway is committed to providing quality services. Prior to your evaluation please review our Terms and Conditions. All members participating in speech language services must agree to these Terms and Conditions. They can be found at https://speechpathway.net/terms-conditions/.

 

Policies and Procedures

Speech Pathway is committed to providing every child with medically necessary Speech-Language services. Prior to beginning services all parents will be provided and asked to sign a copy of our Policies and Procedures. Our Policies and Procedures are available on our website at www.speechpathway.net.

By signing below, I hereby authorize Emily Hathaway and associates at Speech Pathway to evaluate, as well as provide any subsequent treatment based on the evaluation results for Speech Therapy for child names on this form.  I certify that I am a legal guardian and have authority to give consent for medical services. In addition, by signing below I have read and agree to the Terms and Conditions as well as the Policies and Procedures of Speech Pathway.

Printed Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Confirmation Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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