Patient Intake Form

Haga Clic Aquí para una Versión en Español.

If your child is already being seen by one of our clinicians, CLICK HERE to fill out the correct consent form.

Otherwise, continue below.

X/Twitter
This field is for validation purposes and should be left unchanged.
Patient Information
Patient Name*
First Middle Last
Patient Date of Birth*
Legal Guardian*
Phone*
Alternate Phone
Email*
Confirmation of Signer*
- I confirm that I am the above named legal guardian for the child and will be signing consents on their behalf
- I am not the above named legal guardian for this child and will not sign for treatment
Not the legal guardian? Check one below*
- I am filling out the form with the above named legal guardian and they will physically sign this electronic form.
- I am filling out this form on behalf of the above named legal guardian and they are not here to physically sign it themselves.
Referrer Name*
Referrer Phone*
What are you requesting?
- Speech and Language Evaluation (your child has not been evaluated for speech and language services - this will determine if they need therapy)
- Speech and Language Therapy (you have already had an evaluation in the past year - we will request a copy of it)
Patient Address*
Street Address Address Line 2 City State ZIP Code
Patient Mailing Address
If different than address above

Street Address Address Line 2 City State ZIP Code
Person Making Referral
Referral Source Phone
Who is the patient's physician?*
Please leave the name of the physician and the practice.
Physician's Phone
Location of Services
- Home
- School / Daycare
- Office
- Teletherapy
Name of School or Daycare
Time / Availability
Does child currently receive speech services?
- Yes
- No
Does child have an IEP?
- Yes
- No
What languages are spoken in the home?*
Has your child passed a hearing screening within the last year?*
- Yes
- No
- Unsure
Are there any concerns about your child's ability to hear?*
- Yes
- No
Results of the hearing screening
- Pass
- Fail
Please list when and where the screening occurred.
Please describe the concerns you have for your child.
Patient Payment/Insurance Information
If your child has Medicaid, please put their Medicaid number and select their Managed Care Organization (MCO) as well as adding the subscriber ID for their chosen organization.
Medicaid
- Medicaid
- Health Choice
- United Health Care Community Health Plan of NC
- Carolina Complete of NC
- Healthy Blue of NC
- Amerihealth Caritas of NC
- Wellcare of NC
Medicaid Number
Health Choice Number
United Health Care of NC Number
Carolina Complete Number
Healthy Blue Subscriber ID Number
Amerihealth Caritas Number
Wellcare of NC Number
Please upload a picture of the front and back of your child's medicaid card:
Front of Card
Max. file size: 512 MB.
Back of Card
Max. file size: 512 MB.
Primary Health Insurance
This insurance will be billed first if you have Medicaid
Insurance Company Name
Insurance Company Phone
Patient ID Number
Policy/Group Number
Insured's Name
First Middle Last
Insured's Date of Birth
Insured's SSN
Please upload a picture of the front and back of your child's primary insurance card:
Front of Card
Max. file size: 512 MB.
Back of Card
Max. file size: 512 MB.
Other Primary Health Insurance
This insurance will be also billed first if you have Medicaid
Insurance Company Name
Insurance Company Phone
Patient ID Number
Policy/Group Number
Insured's Name
First Middle Last
Insured's Date of Birth
Insured's SSN
Please upload a picture of the front and back of your child's other insurance card:
Front of Card
Max. file size: 512 MB.
Back of Card
Max. file size: 512 MB.
Where did you hear about our company?
- Speech Therapist
- Doctor
- Google
- Internet (Another Search Engine)
- Social Media
- Another Client
- Word of Mouth
If you heard about us through a speech therapist, what was their name?
First Last
Consent Authorization Forms
MEDIA RELEASE AUTHORIZATION (OPTIONAL)*
This Media Release is separate from the Authorization to Photo, Video, and Voice Record for Assessment and Therapy. Your decision below applies only to the use of photographs and/or videos for educational, training, marketing, public relations, or promotional purposes. Your decision will not affect our ability to photograph or record your child as part of assessment, therapy, documentation, or communication with you as described in the Consent for Treatment.

Please select one:
- I GIVE PERMISSION for my child to be photographed and/or videotaped for the purposes of education, training and public relations. The identity of the children will be treated confidentially and your child’s full name will not be disclosed.
- I DO NOT GIVE PERMISSION for my child to be photographed and/or videotaped for the purposes of education, training and public relations.
Select one of the following:
- My child's face may be visible in photos and/or videos.
- Photos and/or videos may be used only if my child's face is not visible.
Optional Email Communications*
This authorization is separate from communications related to your child's care. Your selection below applies only to optional newsletters, clinic announcements, educational resources, special events, and marketing communications.

Regardless of your selection, Cheshire Center may still contact you by email regarding your child's treatment, appointments, scheduling, billing, insurance, required forms, account information, and other administrative or clinical matters necessary to provide services.

Please select one:
- I GIVE PERMISSION for Cheshire Center to send me email updates regarding clinic and therapy updates as well as parent information and helpful reminders pertaining to speech and language therapy.
- I DO NOT GIVE PERMISSION for Cheshire Center to send me email updates regarding clinic and therapy updates as well as parent information and helpful reminders pertaining to speech and language therapy.
Consent for Treatment
USES AND DISCLOSURES OF HEALTH INFORMATION Cheshire Center uses your personal health information primarily for evaluation and treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Cheshire Center may use your personal health information to contact you via phone, email or text message to provide appointment reminders or information about treatment. We may share your health information for continuing, planning and coordinating treatment with appropriately related facilities or professionals involved with your care. Cheshire Center may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. Cheshire Center's policy is to obtain your written authorization before disclosing your personal health information. Cheshire Center may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. If you are concerned that Cheshire Center may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice. You may also send a written complaint to the US Department of Health and Human Services.

PATIENT'S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information, request corrections to any inaccurate or incomplete information, and request a list of instances where your information has been disclosed for purposes other than treatment, payment, or administrative needs. Our practice maintains HIPAA compliance for all records and documentation we generate and store. Please note that if you choose to record your child’s session (audio or video), that recording will not be maintained or protected by our practice and may not be HIPAA-compliant. By choosing to record, you accept responsibility for safeguarding the recording and for any disclosures of information it may contain. You may also request, in writing, that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Cheshire Center will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

CONSENT FOR CARE: I grant permission to the professional staff or their designees at Cheshire Speech & Voice Center, Inc. to render treatment or diagnostic procedures as deemed necessary during my care. I am aware that the practices of speech - language pathology and audiology are not exact sciences and acknowledge that no guarantees have been made regarding the result of treatments or evaluations.

VIRTUAL THERAPY INFORMED CONSENT: I understand that I (legal guardian of patient) may engage in virtual therapy (teletherapy) with my Cheshire Center provider. I understand that virtual therapy services are not the same as in person therapy sessions and that to achieve the best results, I should be in a quiet place with limited interruptions when I am engaged in each session. I understand the potential risks to this technology include interruptions, unauthorized access and technical difficulties. I understand that online therapy presents unique risks to my confidentiality including variables on my end such as others in the vicinity overhearing the session or captured internet transmissions. I understand my provider will inform me and obtain my consent if another person is present during the session and I agree to inform my provider if there is another person present during the session. I understand that I cannot record virtual sessions. I understand that I may work with my provider and withdraw my consent for virtual services at any time and that my provider may terminate virtual therapy if they deem it inappropriate for me to continue under this service delivery model. I understand that Cheshire Center will make every effort to confirm that my commercial or private insurance will cover virtual therapy and that I am financially responsible. (Excludes Medicaid and NC Healthchoice)

CONSENT FOR SERVICES PROVIDED BY SLP-ASSISTANT: Cheshire employs NCBOE registered Speech Language Pathology Assistants under the direction of Certified Speech Language Pathologists in accordance with strict NCBOE licensing requirements and scope of practice guidelines. Speech therapy services at Cheshire may be delivered by both SLP-Assistants and SLPs.

AUTHORIZATION TO PHOTO, VIDEO, VOICE RECORD: As part of the assessment and therapy process, it is often helpful to take photographs, video recordings, or voice recordings of children while working with them. These recordings allow us to review performance, critique therapy practices to improve effectiveness, and compare progress over time. Photos are also useful for data collection and for sharing quick images of your child demonstrating new skills. Please note that video recordings may occasionally be taken on non-HIPAA compliant devices for therapeutic purposes. Parents/guardians have the right to decline or withdraw permission for photography, video, or voice recording at any time by submitting a written request.

ARTIFICIAL INTELLIGENCE DISCLOSURE/CONSENT: The practice may use secure digital tools, including artificial intelligence (AI)-supported systems, to assist with documentation, care planning, and clinical analysis. These tools may help with tasks such as drafting reports, developing goal language, or analyzing speech and language patterns. All clinical decisions, interpretations, and treatment plans are made solely by licensed speech-language pathologists. AI tools are used only as a support and do not replace professional judgment. In some cases, voice recordings may be used to support clinical speech and language analysis. When AI tools are used, the practice follows its AI Policy to ensure the protection of protected health information (PHI), including the use of de-identification when appropriate, encryption, and secure access controls in accordance with HIPAA regulations. We do not use client recordings or personal health information for general AI model training, research, or product development without your explicit additional written consent.

ARTIFICIAL INTELLIGENCE DISCLOSURE/CONSENT: The practice may use secure digital tools, including artificial intelligence (AI)-supported systems, to assist with documentation, care planning, and clinical analysis. These tools may help with tasks such as drafting reports, developing goal language, or analyzing speech and language patterns. All clinical decisions, interpretations, and treatment plans are made solely by licensed speech-language pathologists. AI tools are used only as a support and do not replace professional judgment. In some cases, voice recordings may be used to support clinical speech and language analysis. Any data used with these tools is either de-identified when possible or protected in accordance with HIPAA regulations, including encryption and strict access controls. We do not use client recordings or personal health information for general AI model training, research, or product development without your explicit additional written consent.

AUTHORIZATION FOR USE OR RELEASE / DISCLOSE OF INFORMATION: I authorize Cheshire Speech & Voice Center, Inc. to release clinical information and billing information including, but not limited to, information about my diagnosis, care and treatment for the following reasons.

FINANCIAL COVERAGE: To any third party or its agents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost and appropriateness of care.

USE OR DISCLOSURE FOR CONTINUED CARE: To the referring party or to any physician, therapist, extended care facility, hospital, home health care agency, LEA / school, day care, CDSA, child service coordinator, early interventionist or other such institution needing such information for continued care.

AUTHORIZATION TO REQUEST INFORMATION: I authorize Cheshire Speech & Voice Center, Inc. to request any information needed for continued care from any physician, therapist, extended care facility, hospital, home health care agency, LEA / school, day care, CDSA, child service coordinator, early interventionist or other such institution.

AUTHORIZATION FOR RELEASE OF CURRENT CLINICAL INFORMATION: I authorize Cheshire Speech & Voice Center, Inc.to release clinical information contained in evaluations completed by a g encies other than Cheshire Speech & Voice Center, Inc. to any third party or its agents requesting clinical and other information for the purpose of determining eligibility for insurance or other public benefits; processing insurance claims; or assessing quality, cost, and appropriateness of care.

AUTHORIZATION FOR PAYMENT OF MEDICAL BENEFITS: I authorize billing of insurer by Cheshire Speech and Voice Center and payment of medical benefits to Cheshire Speech & Voice Center, Inc. for services rendered.

WAIVER, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE: In consideration of Minor’s participation in Cheshire Center programs I, in my legal capacity as parent / guardian of Minor agree on behalf of myself and Minor that The Cheshire Speech and Voice Center it’s officers, directors, agents, employees, insurers, and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness, or disease incurred by Minor, however occurring, including but not limited to the negligence of releases. I understand that Minor and I will be solely responsible for any loss, damage including personal injury, disability, or sickness sustained from participation in our services.

COPARENTING POLICY: Cheshire Speech & Voice Center, Inc. recognizes that many of the families we serve are navigating coparenting dynamics. In order to provide a supportive and respectful environment for all families, we have established the following policies. Your signature on this document indicates you understand and agree to the following: -Equal Parental Rights: Both parents have equal rights to attend treatment sessions and access patient records. If there are any special circumstances that affect this arrangement (such as a custody agreement), please provide a copy of the custody order and/or parenting agreement as soon as possible. Please allow up to one week for us to process any necessary changes based on this documentation. We cannot exclude one parent from the treatment process based solely on the preference of the other. -Communication Expectations: It is the responsibility of the parents to communicate with each other regarding therapy schedules, progress, and cost. -Scope of Practice: Our clinicians are specialists in speech-language therapy. Assessing the nature of a parent-child relationship or making custody-related recommendations is outside of our professional scope. We will only testify or provide documentation related to the child's therapy progress and treatment. - Legal Involvement Fees: - Expert Testimony: $150.00 per hour (includes travel and wait times) plus $0.70 per mile from our office to the courthouse. A subpoena is required, and your attorney must provide questions at least 24 hours in advance for adequate preparation. - Notarized Documentation: $100.00 (subpoena required). Non-notarized daily notes, progress reports, and evaluations are available at no cost. We do not provide letters of recommendation or support for custody arrangements. - Handling of Coparenting Issues: All matters related to coparenting conflict will be addressed by the Clinical Director, Laura Michael. This ensures your child’s therapist and our administrative team can remain focused on delivering high-quality care.

I HAVE READ AND UNDERSTAND THIS INFORMATION.I HAVE RECEIVED A COPY.I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.
Patient Information Consent
I have read and fully understand Cheshire Center's Notice of Information Practices. I understand that Cheshire Center may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I also understand that Cheshire Center will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Cheshire Center's Notice of Information practices.

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY. I AM EITHER THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.
Cheshire Center Payment Contract
Thank you for choosing Cheshire Center! We are committed to your entire experience being successful. We will need complete and accurate payment and insurance information. If you have commercial insurance or are private pay, you will need to speak to our billing specialist in order to have a general understanding of your financial responsibility prior to seeing one of our therapists.

Your account balance is due weekly. We require a form of payment being placed on file prior to services being provided. Payment will be automatically deducted the week after services are provided. Acceptable payment options include Visa, Mastercard, FSA, and Care Credit. Unpaid balances are subject to collections through an outside agency.

Make up visit policy: Plans of care are written based on medical necessity. Should services be missed, make up services will be provided.

Medicaid or NC Healthchoice patients: We do not require a form of payment on file. You are financially responsible for services rendered and a form of payment will be required to continue services should you lose your coverage.

Sometimes your insurance may change during the course of treatment services. You are required to notify us immediately and provide updated information. Our billing specialist may be reached at 336-375-2240.

I have read and understand the payment contract and agree to abide by this policy
Cheshire Center Attendance Policy
Therapy is most successful when the child attends and receives the recommended number of therapy sessions each week per their plan of care. Currently we have a waiting list of patients for our services and therefore must monitor and strictly enforce our attendance policy in order to maximize the time our therapists have available to serve children. POLICY: MISSING THREE OUT OF FIVE scheduled sessions will result in discharge from services. Once a patient has been discharged for attendance, they can not be referred back to our office for services for a minimum of six months and will be subject to our waitlist if applicable at the time. Some exceptions may apply.

Please openly discuss any scheduling conflicts you have with the therapist. Perhaps your current therapist, or another one will have a future opening that would be better for you if they are aware of your preferences. It is imperative to communicate.

We require that you inform the therapist as soon as you know your child will not be available for a therapy session. Ex: upcoming vacations, field trips etc. Given advanced knowledge of such a trip, your therapist may be able to schedule an additional session to make up for the one(s) your child will miss.

Cancellations with a minimum of 24 hours notice is required so that our therapists can efficiently plan their day and accommodate others. We do acknowledge that sometimes life happens and cancellations are unforeseen so please notify your therapist as soon as possible if 24 hours notice is not possible. It is our intention to prevent unnecessary travel and expense on the part of the therapists therefore late cancellations will still count as missed sessions and we require your call/notification even if we see your child in daycare or preschool as sometimes the therapist is traveling to that center for a single session.

Thank you for your cooperation and consideration of our therapists’ time and again for allowing Cheshire Center the opportunity to work with your child. Should you have any questions or concerns regarding this policy, please call the clinical director, Rebecca Eaton at Cheshire Center: 800-360-1099 or email: reaton@cheshirecenter.net.
Consent*
I have read and agree to the Consent for Treatment, Patient Information form, Payment Contract, and Attendance Policy above.

Patient Information

Patient Payment/Insurance Information

Please upload a picture of the front and back of your child's medicaid card:

Primary Health Insurance

Please upload a picture of the front and back of your child's primary insurance card:

Other Primary Health Insurance

Please upload a picture of the front and back of your child's other insurance card:

Consent Authorization Forms

Consent for Treatment

Patient Information Consent

Cheshire Center Payment Contract

Cheshire Center Attendance Policy

Newsletter

Let's Keep Talking

Helpful Links