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.
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 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.
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”.
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.
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.
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 ***
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 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.
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.
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.
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.
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.
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.
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.
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.
If your child receives Special Education Services please provide us with a copy of your child's most recent IEP.
Provide the approximate age at which the child began to do the following activities:
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.
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!
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
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.
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.
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.
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
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/.
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.