Online Evaluation Intake Online Intake Step 1 of 6 16% General InformationChild's Name(Required) First Last Child's Date of Birth(Required)Grade Level(Required)School(Required)Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent 1 Name(Required) First Last Parent 1 Email(Required) Parent 1 Cell Phone(Required)Parent 1 Place of Employment(Required)Parent 1 Work Phone(Required)Parent 2 Name First Last Parent 2 Email Parent 2 Cell PhoneParent 2 Place of EmploymentParent 2 Work PhoneParent 2 Address (If Different from Home Address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of Pediatrician(Required)How did you hear about us?(Required)Year of Last Vision Screening(Required)Vision Screening Results(Required) Pass Did Not Pass Year of Last Hearing Screening(Required)Hearing Screening Results(Required) Pass Did Not Pass What school does your child attend?(Required)Has your child ever repeated a grade?(Required) No Yes If yes, which grade?When did you first begin to have concerns about language or literacy skills?(Required)Has the school ever provided an evaluation for your child?(Required) No Yes If yes, please explain.Has the school ever provided an IEP for your child?(Required) No Yes If yes, please explain.Has the school ever provided a 504 plan for your child?(Required) No Yes If yes, please explain.Has the school ever provided MTSS/RTI supports for your child?(Required) No Yes If yes, which subject?Place a check next to any of the following issues that occur among parents, siblings, or grandparents: Dyslexia/Reading Difficulties ADHD Autism Auditory Processing Language Disorder Articulation Disorder Anxiety Depression Did your child meet developmental milestones such as walking, talking, toileting, within expected timeframes?(Required) Yes No If no, please explain.Place a check next to any of the following professionals you have visited for a private evaluation: Speech-Language Pathologist Physical Therapist Psychologist Occupational Therapist Audiologist Neuropsychologist Other If other, please specify.Please provide the name of the place(s) where the private evaluation was done and the results.Place a check if you have received any of the following: Speech-Language Therapy Physical Therapy Mental Wellness Occupational Therapy Reading Therapy Vision Therapy Please provide the name of the provider(s) and tell us when the services occurred.Are you currently receiving any of the above therapies?(Required) Yes No If yes, which ones?What do you hope to achieve with this evaluation?(Required)What extracurricular activities does your child enjoy?(Required)What do you admire most about your child?(Required)Preparing for Your EvaluationIf your child has had an evaluation before, you are welcome to upload it here. If you prefer, you can also send that information by mail.Max. file size: 512 MB.As a reminder, do not send sensitive information through email. Email is not considered compliant with HIPAA standards.File 2Max. file size: 512 MB.File 3Max. file size: 512 MB.File 4Max. file size: 512 MB.File 5Max. file size: 512 MB.I have been informed that a school is not required to accept findings of a private evaluation. I understand that a diagnosis does not guarantee any action/services will be provided by a school or other entity.Parent Signature(Required)Date(Required) MM slash DD slash YYYY Evaluation Intake - Informed ConsentI am a parent/legal guardian of the child and have carefully read and fully understand that I am giving informed consent for Educational Inspiration to evaluate my child. I have had the opportunity to discuss this evaluation with the clinician by phone and/or in person.I understand that an evaluation is not a guarantee that a diagnosis/specific diagnosis will be given. I understand that a diagnosis does not guarantee any action or services by a school or other entity.I understand that the evaluation will be carried out by Nicole Power, M.S., M.Ed., CCC-SLP, a licensed and certified speech-language pathologist and reading specialist. I hereby give consent to Educational Inspiration to evaluate my child.Signature of Parent/Legal Guardian(Required)Date(Required) MM slash DD slash YYYY Evaluation Intake - Permission to Record Voice and Photograph Work SamplesAudio recordings as well as photographs are often utilized in the evaluation process.Voice recordings are especially useful to aid in transcription of story retells or lengthy answer responses given during a test so they may be further analyzed. These voice recordings are destroyed once the evaluation is complete.Photographs of work produced during the evaluation sessions are included in the final family report as evidence in support of conclusions drawn. Photos may include, but are not limited to, alphabet letters and stories. Photographs only include work samples and never include your child's image. Photographs are often saved and shared (with names removed) as part of university teaching and professional development programs.Parent/Legal Guardian ConsentI understand that I am giving consent for Educational Inspiration to record my child's voice and photograph work samples in order to create a well-rounded and thorough evaluation with supporting evidence. I understand that some photos of work samples (with my child's name removed) may be used as part of a professional teaching program.Signature of Parent/Legal Guardian(Required)Date(Required) MM slash DD slash YYYY Evaluation Intake - Good Faith EstimateIn January 2022, the No Surprises Act went into effect. This means that as a private pay patient, you are entitled to a Good Faith Estimate. During our telephone consultation, you were informed of the services that would be provided and the cost of the service prior to booking an appointment.The total cost of the evaluation is provided during the phone consultation and in the written appointment confirmation. The fee is expected by cash or check at the first appointment.The evaluation may include:1. Assessments related to speech-language, reading, spelling, and writing skills.2. Up to six hours of direct assessment for an initial evaluation or up to three hours of direct assessment for a re-evaluation.3. Scoring of tests.4. Analysis of assessments, including written work samples.5. Compilation of results into a report provided at a family meeting. You will receive your report at the time of the meeting, approximately four weeks from the final date of the evaluation. A re-evaluation report may be significantly shorter than an initial evaluation report.Cancellations:You may cancel your appointment with no charge with 48 hour notice. If your child is suddenly sick less than 48 hours from your appointment, you may reschedule at no charge; however, if you choose not to reschedule you will be charged a $100 fee. No-Shows will be charged a $200 fee.You may contact us at 405-285-1475.Good Faith Estimate ConfirmationI was provided a Good Faith Estimate at least one week prior to my appointment. I have read and understand the costs and services associated with this evaluation.Signature of Parent/Legal Guardian(Required)Date(Required) MM slash DD slash YYYY Evaluation Intake - Health Insurance Portability and Accountability Act (HIPAA)Protection of Health Information:HIPAA requires us to keep your health related information private. This includes your medical history, diagnostic evaluations, and therapeutic services.Uses and Disclosures of Your Protected Health Information:Disclosure of your health information may occur during treatment. Examples include law enforcement and voicemails/texts/emails.Your Rights Regarding Health Information:You have the right to review your health information which might include intake and reports. Your authorization is required to send/receive information from schools or teachers.Notice of Privacy ConfirmationThis practice reserves the right to change/update this notice at any time. If you believe your privacy rights have been violated, submit a complaint to the US Department of Health and Human Services. I have reviewed and understand this Notice of PrivacySignature of Parent/Legal Guardian(Required)Date(Required) MM slash DD slash YYYY Evaluation Intake - Text/Email PoliciesRisk of using email/text/voice messages:1. May be circulated, forwarded, stored, misaddressed, or sent to unintended recipients.2. Back up copies may exist even after they have been deleted.3. May be used as evidence in court.4. Confidentiality may be breached by unintended/unknown third parties.Conditions for use of email/texts/phone calls:1. Clinician uses reasonable means to maintain security and confidentiality.2. Clinician is not liable for improper disclosure not caused by intentional clinician misconduct.3. Families should call to discuss sensitive information rather than email/text/leave messages.4. Emails or texts may be printed and saved as part of client's file.5. Clinician will not forward emails/texts/voicemails without written consent.Parent/Legal Guardian ConsentI have read and understand the policy and risks associated with use of email/text/voicemails. I consent to the use of texts/emails/phone messages between myself and the clinician.Signature of Parent/Legal Guardian(Required)Date(Required) MM slash DD slash YYYY
