Intake & Consent Form - FAST Program - Ruby Speech Therapy Inc.

First Name *

Last Name *

The above First and Last Name should be for the child, unless you are filling out this form for yourself.

Contact Information

Child's Date of Birth *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Phone Number *

Email *

Street Address *

Town/City *

Postal Code *

Emergency Contact *

Does your child currently attend a daycare/pre-school/school? If so, please list the name of the daycare/school. *

NoYesNo

Client Background

The following questions are worded for parents filling out this form for their child. If you are filling out this form for yourself, please answer relevant questions for yourself.

Language(s) spoken in the home *

Family history of speech and/or language delays or disorders?

Has your child had his or her hearing tested? If yes, what were the results? *

NoYesNo

Early Medical History & Developmental Milestones

Please describe any complications in pregnancy, birth, or any relevant medical history (i.e., hospital stays, surgeries, etc.)

Please describe any concerns with feeding (as an infant or currently), sleeping (e.g., snoring, open mouth breathing) or breathing (e.g., chronic congestion, open mouth breathing when awake).

Please describe any concerns with early developmental milestones (e.g., crawling, walking, feeding, etc.)

At approximately what age did your child begin to babble (bababa, dadda, etc.) ?

At approximately what age did your child say their first word?

Current Information & Presenting Concerns

Please select any/all areas of concern. We will discuss each area in more detail at your first appointment.. *

Please answer this question.

How does your child currently communicate? For example, do they use gestures, picture symbols, single words, short phrases, or tell long stories? Sharing a bit about this will help us prepare for your first session.

Has your child previously received speech therapy, occupational therapy, or other services (e.g.., early intervention, PUF pre-school programming, etc.)? If yes, please describe. *

NoYesNo

Does your child have any relevant diagnoses or are they on the waitlist for any assessments (e.g., dyslexia, autism spectrum disorder, etc.)? If yes, please describe. *

NoYesNo

Please share some of your child's current interests (e.g., games, toys, characters, activities, songs, shows, etc.). *

Clinic Policies & Patient Consent

Please read and mark your initials after each section.

As part of your application for the FAST program at Ruby Speech Therapy Inc., you are required to submit documents to demonstrate financial need. You may choose to submit this information by mail or via email. If submitting by email, we strongly recommend enhancing email security by sending documents in a password-protected format. If you are using Gmail, we strongly recommend sending confidential documents using the confidential mode (please enable "SMS passcode" as well as copy, print, and download functionalities for 1 month) ; otherwise, please use a password protection on the files you send, and call or text us the password(s).

Parent/Guardian Initials *

Your appointment time has been reserved for your child. Your therapist has spent time preparing for your appointment and will be unable to fill that spot if you cancel. If you must cancel, please give us at least 24 hours notice by texting our business line (780-802-4052) or emailing paulina@rubyspeech.com. If you give less than 24 hours notice, you will be charged your established rate for the session. Your therapist will still use your session time to work on your child's case (for example, preparing materials or homework, writing a progress note, or communicating with your child's school, if applicable).

Because the clinic is a shared space, you agree not to bring your child if you or they are sick.In the event of illness, your therapist can provide a virtual session, a parent coaching phone call, or spend the session working on your child's case. As previously stated, sessions that are cancelled with less than 24 hours notice are billed in full.

Parent/Guardian Initials *

Ruby Speech Therapy is authorized to use electronic communication and storage hosted by Google Workspace for correspondences (e.g., invoices, receipts, email correspondences, reports) regarding my child's case.

Parent/Guardian Initials *

Rates billed as part of the FAST Program are dependent on each family's application and approval with the clinic. You will separately sign an agreement for your approved rate for Speech-Language Pathologist (SLP) services and Speech-Language Pathologist Assistant (SLPA) services.

All charges will be discussed with you ahead of time.

1 clinical hour is equivalent to 45 minutes of face-to-face time in session, followed by 15 minutes of indirect time set aside for documentation, email follow-up, or resource sharing as needed.
40-minute sessions include 30 minutes together, followed by 10 minutes of indirect time.
Extended sessions will be billed in 5-minute intervals.
All professional services, including electronic communications, school visits, meetings, case conferences, grant applications, supervision, and documentation, will be charged at the same rate.

Parent/Guardian Initials *

To pay for services, you have the option to use either a Credit Card or a Visa or Mastercard Debit card. Here's how the process works:

First Payment: For your initial payment, you'll receive an invoice with a link to "Pay Invoice". Clicking this link will direct you to a secure page where you can enter your card details.
Card Processing and Storage: The card information you provide is securely processed by Stripe. Your card details are securely stored by Colib, an Electronic Records Management system
Subsequent Payments: For any future invoices, Ruby Speech Therapy, Inc. will automatically charge the card you have on file.
Receipts: After each payment, you will receive a receipt for your records.

In the event that payment with your card on file does not go through, payment is due within 24 hours of receiving the invoice.

If an invoice is not paid within 24 hours, it will be considered a late payment. There is a $35 fee for each late payment, and $5 is added for each additional day that payment is late.

For any amount that is 30 days past due, our clinic will use the services of a debt collection agency, solicitors, or third parties to recover the debt. The clinic reserves the right to share contact information and overdue invoices with these third-party agencies for payment collection.

Again: all charges will be discussed with your in your specific payment agreement based on your FAST Program application.

Parent/Guardian Initials *

Ruby Speech Therapy is authorized to take photographs, audio and video recordings of clients for assessment and therapy purposes (only to be viewed by the therapist working with your child). The therapist will also ask for consent at the time of assessment or treatment, as needed, and this consent can be revoked at any time.

Parent/Guardian Initials *

By submitting this form, you give consent for Ruby Speech Therapy Inc. to contact you via email, phone call, or text for intake process, scheduling, updates, promotions, and newsletters. We respect your privacy and do not share or sell your personal information. You may unsubscribe from our updates at anytime.

Parent/Guardian Initials *

Signature

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :

Intake & Consent Form - FAST Program - Ruby Speech Therapy Inc.

Thanks for completing the form.

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Thanks for completing the form.

The information has been received.

Contact Information

Client Background

Current Information & Presenting Concerns

Clinic Policies & Patient Consent

Signature

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