If you have returned the New Client Intake form to us and have spoken with our office to schedule therapy,
please use the forms below to enroll as a client. You may return them to us at pathwayspeech@verizon.net
Pathway Speech & Language, Inc.
2625 E. Southlake Blvd., Suite 100
Southlake, TX 76092
817-424-4299
pathwayspeech@verizon.net
www.pathwayspeech.com
POLICY INFORMATION
**Please retain pages 1-2 of the policy information sheets for your records.**
Gail Lindley and her team of qualified therapists provide Speech and Language therapy, Pathway Scholars (reading) and Social Thinking Groups, twelve months of the year. Our team also provides speech and language assessments and social thinking assessments. We also offer hearing/vision screenings to local area private schools. All of our speech language pathologists hold a Masters degree, have been awarded their Certificate of Clinical Competence (CCC), are licensed by the State of Texas and are members of the American Speech, Language and Hearing Association. Our Social Thinking Mentor, Cherie Bennett, has trained with Michelle Garcia Winner, MS CCC/SLP at her clinic in San Diego, CA. John Hodges, our Pathway Scholars tutor, was trained at The Shelton School of Dallas.
Office Hours:
Our office phone number is 817-424-4299
Our regular office hours are Monday - Thursday, 9 a.m. to 5 p.m., 12 months of the year.
We are not open:
1. During regular school holidays; i.e., Spring Break, President’s Day, etc.
2. Good Friday; the week of Thanksgiving and Christmas.
Inclement Weather:
We will be closed, due to inclement weather, on any day that the newscasters announce area school closures. (GCISD, CISD, KISD, NWISD)
Contacting Clinicians:
Clinicians will make every effort to contact parents on a regular basis especially those parents whose children are seen at school during the school day. However, we encourage parents to call us at any time they wish to be updated on therapy progress. Please let us know, and provide an email address, if this mode of communication is preferable.
Pathway Team:
Gail Lindley 817-944-3553 gailyt@verizon.net
Amber Cloy 817-522-2732 amberb2222@yahoo.com
Annette Faehnle 757-343-3661 annette.faehnle@charter.net
Kris Power
Cherie Bennett
John Hodges
Cancellation Policies:
Since we reserve your appointment time for you, and therapy progress depends on consistency, we ask that you be considerate when deciding to cancel appointments.
Notification 24 hours in advance is required to avoid being billed for your appointment. Please contact your therapist directly when cancelling appointments.
You will not be billed for appointments cancelled by your therapist. _____ (initial)
A 2-week notice is required for discontinuing your child’s therapy. _____ (initial)
Payment & Late Payment Policies:
Our fee for therapy at our clinic is $50.00 per 1/2-hour therapy session. Bills are sent via email at the beginning of each month for the upcoming month’s services. Payment is due on the 5th of the month. A 5% late fee will be applied if payment is not received on that date and a new invoice will be emailed. Another 5% fee will be applied if payment is not received by the 20th of the month. If fees are not current by the last session of the month, therapy will be temporarily postponed until the balance is paid in full. We accept checks, MasterCard, Visa and debit cards.
Credits to Accounts:
All corrections to billing will be applied to invoices the following month.
Insurance:
We require payment for services directly from our clients. However, if you have speech therapy coverage on your insurance policy, we will assist with any correspondence that you need in order to file claims. Please save your invoice copies for future use in dealing with insurance claims. There is a $25 fee for additional invoice copies.
Release of Information:
We ask that you sign a release form should you require us to share your reports/records with other professionals.
Optional Home Activities:
Some parents feel comfortable working with their children at home and others do not. Please let your clinician know if you wish to have suggestions and worksheets to use at home to help in the carryover of therapy goals.
*All of our speech language therapists are licensed by the State of Texas and certified by the American Speech-Language Hearing Association.
"Your word is a lamp to my feet and a light to my path"
Psalm 119:105.
Pathway Speech and Language
Clinic Policies
*Please complete this form, sign and return it to the office.*
**Please retain pages 1-2 of the policy information sheets for your records.**
I have read and understood the above policies regarding fees, cancellations and collections.
Child’s Name:
Parents' Names: Mr. and Mrs. ( )
Spouse's Name
Address:
(City) (State) (Zip)
Telephone: ( )
Child’s Age: years, month(s)
Child’s Birth Date:
Child’s School:
Child’s Therapist:
Email:
Parent Signature:
Date:
Rev 08/11
NEW CLIENT INFORMATION FORM
Pathway Speech and Language, Inc.
2625 E. Southlake Blvd., Suite 100
Southlake, Texas 76092
817-424-4299
pathwayspeech@verizon.net
pathwayspeech.com
SPEECH LANGUAGE THERAPY
Dear Parents:
Your completion of this form will help us get to know your child a little better! Please note that this information will be
kept confidential and will not be released without written permission from you. If additional space is needed, please feel
free to attach additional pages for your comments. Your comments and concerns are of great value to us. Please write legibly.
Date: _________________________
Referred by: _____________________________________________________________
PERSONAL INFORMATION:
Person filling out this form: Father: _____ Mother: ____
Other: _____________________
Child’s Name: ____________________________________________________________
Sex: ________ Age: ___________ Date of Birth: ________________
Current Grade: _________School: _________________________Teacher: ___________
(If applicable)
Child lives with: __________________________________________________________
Address: ________________________________________________________________________ (include city, state, zip)
Phone number: ___________________________Cell phone:_______________________
Email: ____________________________________
List names, as appropriate:
Father____________________________________Step-father______________________
Mother___________________________________Step-mother_____________________
Other Specialists consulted:
Name: _____________________________________Date________________________
Their diagnoses/findings/recommendations: _______________________________________________________________________
________________________________________________________________________
My child’s strengths include: _______________________________________________
____________________________________________________________________________________________
____________________________________________________
My child’s weaknesses include: ____________________________________
____________________________________________________________________________________________
____________________________________________________
BIRTH AND DEVELOPMENTAL HISTORY:
Was your child adopted: _______________?
If yes, age at time of adoption_____________
Pregnancy: Term: ____________ Duration of labor: __________
Weight at Birth: ___lbs. ____oz. Color at birth____________ Strength of suck_______
Ceasarean Section? _________ Reason? _____________________________________
Extended hospital stay? _______ Reason? ____________________________________
Trauma at delivery? _________ Explain: _______________________________________
Child’s first year: Active______ Passive_______ Contented_______ Fretful________
Colic? _________ Oral motor problems_______________________________________
Allergies________________________________________________________________
PLEASE FILL OUT THE FOLLOWING CHART TO THE BEST OF YOUR ABILITY:
Behavior | Age Accomplished | Comments |
Sat unsupported | | |
Walk unattended | | |
First words spoken | | |
Talked in short sentences | | |
Talked clearly enough that strangers understood | | |
Became toilet trained | | |
Learned to skip | | |
Began bicycle riding with training wheels | | |
Began bicycle riding without training wheels | | |
MEDICAL HISTORY:
Has your child had any of the following: (please give approximate age)
Mumps________ Measles________ Frequent headaches_______________
Frequent colds__________ hay fever_______________
Earaches/infections_________Approximately how many?____________________
Hearing problems__________________________ Tubes? ________________
High fevers Age___________ Cause if known_____________
How high/long? ___________
My child was last seen by Dr. ____________________________ Date: _____________
Examination revealed_____________________________________________________
Is your child taking any medications? ___________________ What? ________________
Dosage________________ Prescribed by_______________________ How long_______
Has you child had a hearing test? _______ When/results___________________________
Has your child had a vision test? _______ When/results___________________________
Is your child on a special diet? __________Restrictions:__________________________
Known Food Allergies:____________________________________________________
Other Allergies we need to be aware of (i.e. latex)______________________________
FAMILY HISTORY INFORMATION:
Please list the members of your family including parents, siblings and extended family members with a history of speech, language or learning differences.
SCHOOL HISTORY (if applicable):
List the names of daycare and schools attended beginning with preschool:
Was entry into first grade delayed by attending Kindergarten twice or a Primer/pre-first grade? ___________
My child’s best subjects are:
_____________________________________________________________________
My child has difficulty with:
______________________________________________________________________
My child’s teacher has voiced concerns about:
______________________________________________________________________
Does your child finish his/her work in class independently? _________
If assistance is required, how much/what format?
______________________________________________________________________
Grade History (general)__________________________
GENERAL INFORMATION:
Does your child have difficulty paying attention? ________________________________
If yes, in what situations or environments:______________________________________
_______________________________________________________________________
Does your child have difficulty playing or working independently? _______
If yes, please describe: _____________________________________________________
________________________________________________________________________
Does your child have difficulty interacting with peers? _______________
If yes, please describe______________________________________________________
________________________________________________________________________
Is your child overly sensitive to loud noises, touch, and certain tastes? ________
If yes, please describe______________________________________________________
________________________________________________________________________
Any additional information you feel will be helpful over the course of therapy may be written below or on a separate piece of paper. Please include copies of any diagnostic assessments you may have.
Thank you.
Pathway Speech and Language, Inc.
2625 E. Southlake Blvd., Suite 100
Southlake, Texas 76092
817-424-4299
Pathwayspeech@verizon.net
Release of Information Form
(Therapy)
Please read this form carefully. After listing the appropriate names and addresses, sign this form and return it to Pathway Speech and Language. If you have any questions, please feel free to call.
Client’s Name: _________________________________________
Date: _________________________________________________
I, the undersigned, authorize Pathway Speech and Language, to share information, either orally or in written report, with the person(s) listed below. The information regards therapy/evaluations conducted by Pathway Speech and Language, on the above named client, on the above named date.
Physician (e.g., pediatrician, neurologist)
School (e.g., teacher, principal, admissions director)
Therapist (e.g., psychotherapist, reading specialist, tutor)
Other (e.g., non custodial parent, insurance company)
Name of parent or legal guardian Date