1752 E Bullard Ave, Suite 101 Fresno, CA 93710 | 4144 S. Demaree St, Suite B, Visalia, CA 93277
Fresno - 559-970-8277
CONTACT
Home
Speech Therapy
Speech Therapy
Feeding Therapy
Literacy Help
We currently offer individualized therapy sessions for clients focusing the following areas of communication:
Articulation
Language
Auditory Processing
Fluency (Stuttering)
Pragmatic (Social) Language
Early Intervention
Behavioral Services
Oral Placement
Pediatric Feeding
Literacy
Speech Therapy
Individualized Services
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Staff
Speech & OT Staff
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Products
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Intake Forms
New Patients
TALK Tidbits
Speech Therapy
Autism
Parent Resources
New Patients
Ortho Child Case History
Step
1
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11
9%
Section 1
General Information
Today's Date
MM slash DD slash YYYY
Child's Name
*
First
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Age
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Allergies
Emergency Contact Information
Name
*
First
Phone Number
*
Relationship to Client
Does the child live with both parents?
Select
Both Parents
Mother
Father
Guardian
If divorced, who has custody?
Select
Joint
Mother
Father
Other
Who does child spend most of his/her time with?
Parent/Caregiver #1 Name
Occupation
Home Phone
Cell Phone
Email
Parent/Caregiver #2 Name
Occupation
Home Phone
Cell Phone
Email
Siblings / Age
Other people in the home / Relation
Section 2
Physician Information
Child's Physician
Phone Number
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Section 3
Child's Behavior
What language(s) does the child speak?
Has your child received any speech therapy, occupational therapy, or physical therapy services? If yes, please describe what was addressed.
Section 4
Is the child adopted?
Select
Yes
No
Unknown
At what age did the child join the family?
Alcohol, drugs, smoking, or any medications during this pregnancy?
Select
Yes
No
Unknown
Please list alcohol, drugs, smoking, or any medications during this pregnancy.
Normal pregnancy and delivery?
Select
Yes
No
Unknown
Did your child have jaundice?
Select
Yes
No
Unknown
Weight at birth
Was oxygen or respiratory assistance required after birth?
Select
Yes
No
Unknown
Vaginal delivery?
Select
Yes
No
Unknown
Was your child breast fed?
Select
Yes
No
Unknown
Cesarean delivery?
Select
Yes, it was planned
Yes, it was a repeat C-section
Yes, it was an emergency
No
Unknown
Any difficulties with feeding?
Select
Yes
No
Unknown
Full-term pregnancy?
Select
Yes
No
Unknown
Did your child have normal feeding, weight gain, sleeping cycles, and temperament?
Select
Yes
No
Unknown
Section 5
Prenatal and Birth History
Describe mother’s general health during pregnancy (illness, accidents, prescription and non-prescription medications, etc.)
Length of pregnancy
Section 6
Medical History
Child’s general health is:
Select
Good
Fair
Poor
Is your child on any medications? If so, please list.
Describe any major illnesses, accidents, surgeries, or hospitalizations the child has had.
Has your child had ear infections?
Select
Yes
No
Unknown
How many ear infections?
Does your child have tubes?
Select
Yes
No
Unknown
Section 7
Developmental History
Please complete this section to the best of your ability. Write the approximate age when the child began to do the following.
Crawl
Sit
Stand
Walk
Feed Self
Dress Self
Use toilet
Coo
Babble
Use single words
Combine words
Name simple objects
Use simple questions
Engage in a conversation
Does your child have any motor difficulty, such as walking or running?
Describe any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing, etc.) your child has had.
Section 8
Educational History
School or Preschool
Grade
Teacher(s)
Describe any special services your child receives.
If enrolled for special education services, list main goals of the Individualized Educational Plan (IEP) or Individual Family Service Plan (IFSP).
Section 9
Orthodontic History
What phases has your child completed so far? Please include ages as well as the work completed:
What are future orthodontic plans?
What are the orthodontist's concerns?
How did you hear about The TALK Team?
Select
Family Member
Friend
Teacher
Doctor
Internet
Phone Book
Workshop
Insurance Network
Other
Section 10
The information provided in this document regarding my child is accurate and consistent to the best of my knowledge.
Electronic Signature
*
Date
MM slash DD slash YYYY
Relationship to the patient
Section 11
I give The Talk Team permission to speak with the orthodontist regarding treatment and concerns.
Electronic Signature
*
Date
MM slash DD slash YYYY
Δ
Informacion del Paciente
Nombre del paciente
*
Nombre completo
Fecha de nacimiento
*
MM slash DD slash YYYY
Nombre del padre / tutor
*
Nombre completo
Teléfono
*
correo electrónico
*
Informacion de Seguro Medico
Proveedor de Seguro Medico
*
* Todas las opciones de seguro están sujetas a verificación de elegibilidad / beneficios *
Kaiser
Sante
PhysMetrics
Otro
Proveedor de Seguro Medico
Sube una foto de tu tarjeta de seguro.
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
Estoy interesado en pagar de forma privada ($ 100 por una sesión de 50 minutos con un patólogo del habla certificado y con licencia)
Informacion de Politicas
marque todos para aceptar terminos
*
Las citas deben cancelarse, como mínimo, con 24 horas de anticipación (las cancelaciones dentro de las 24 horas pueden incurrir en un cargo de $ 50)
Ofrecemos programación flexible o rotativa, no se puede garantizar una cita permanente
Dos cancelaciones tardías / no presentarse pueden resultar en la pérdida del estado de cliente activo
Requerimos el pago dentro de las 48 horas posteriores a la recepción de la factura. El saldo pendiente puede afectar la programación o resultar en la pérdida del estado de cliente activo.
Pedimos a todas las familias que estén abiertas a probar una sesión virtual.
Para niños / dependientes:
El desarrollo de mi hijo fue:
a tiempo
retrasado
Mi hijo ha recibido actualmente o en el pasado:
Terapia del lenguaje
Terapia ocupacional
Terapia física
Terapia de alimentación
Terapia de comportamiento
IEP en la escuela
Intervención rápida
Mi hijo tiene un diagnóstico de:
Autismo
Síndrome de Down
Para Adultos / Independientes
He recibido actualmente o en el pasado:
Terapia del lenguaje
Terapia ocupacional
Terapia física
Terapia de alimentación
Terapia de comportamiento
IEP en la escuela
Intervención rápida
Preocupaciones
Selecione todas las que apliquen
Todavía no hablo
El habla es difícil de entender
Diagnóstico (autismo / síndrome de Down / otro)
Comedor quisquilloso
Tartamudeo
Problemas con las conversaciones / intercambios sociales
Problemas para responder preguntas
El ortodoncista me recomendó / empuje en la lengua
Paladar hendido
Pérdida auditiva
¿Alguna otra reocupaciones?
Horario de Disponibilidad
Disponibilidad para citas de terapia (se indica la hora de inicio de la cita de terapia).
Seleccione un mínimo de 2 opciones a continuación
lunes
Temprano (7-10)
Mediodía (10-1)
Tarde (1-4)
Tarde (4-5)
martes
Temprano (7-10)
Mediodía (10-1)
Tarde (1-4)
Tarde (4-5)
miércoles
Temprano (7-10)
Mediodía (10-1)
Tarde (1-4)
Tarde (4-5)
jueves
Temprano (7-10)
Mediodía (10-1)
Tarde (1-4)
Tarde (4-5)
viernes
Temprano (7-10)
Mediodía (10-1)
Tarde (1-4)
Tarde (4-5)
A que hora seria mejor para contactarlo/a para su consulta?
Δ
CLOSE
Which location are you interested in?
*
Select a location
Fresno
Visalia
Have you ever been a client or received services from Talk Team or Talk ABA, Inc.?
*
Select all that apply
Yes
No
Which services are you interested in?
*
Select all that apply
Speech Therapy
Occupational Therapy
ABA Therapy
Patient Information
Patient's Name
*
Full Name
Date of Birth
*
MM slash DD slash YYYY
Parent/Guardian's Name
*
Full Name
Phone Number
*
Your Email
*
Insurance Information
Insurance Provider
*
*All insurance options subject to eligibility/benefits check*
Kaiser
Sante
PhysMetrics
Other
What Insurance Provider do you have?
*
Please upload a photo of the front of your insurance card
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
Please upload a photo of the back of your insurance card
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
Are you interested in paying privately?
Yes
No
Policy Information
Check ALL to Agree to Terms
*
Appointments should be cancelled, at minimum, 24 hours in advance (cancellations within 24 hours may incur a $50 charge)
We offer flexible or rotating scheduling, a permanent standing appointment cannot be guaranteed
Two no show/late cancellations may result in loss of active client status
We require that a credit card be kept on file, or sessions be pre-paid at the beginning of the month. All sessions will be charged at time of service or within 24 hours.
We ask all families to be open to trying a virtual session.
Concerns
List All Concerns
Schedule of Availability
Availability for therapy appointments (start time of therapy appt is listed).
Please select a minimum of 2 options below
Monday
*
Early AM (7-10)
Midday (10-1)
Afternoon (1-3)
Late (3-5)
Not Available
Tuesday
*
Early AM (7-10)
Midday (10-1)
Afternoon (1-3)
Late (3-5)
Not Available
Wednesday
*
Early AM (7-10)
Midday (10-1)
Afternoon (1-3)
Late (3-5)
Not Available
Thursday
*
Early AM (7-10)
Midday (10-1)
Afternoon (1-3)
Late (3-5)
Not Available
Friday
*
Early AM (7-10)
Midday (10-1)
Afternoon (1-3)
Late (3-5)
Not Available
When is the best time to contact you for your consultation?
*
What is your preferred method of contact?
*
Phone
E-mail
Text
Δ
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