referral form - Function First Pediatrics Inc.

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FUNCTION FIRST PEDIATRICS INC.
th
Suite 101, 8715 – 109 Street, Grande Prairie AB T8V 8H7
Phone: (780) 532-4921 Fax: (780) 532-4963
email: [email protected] www.functionfirst.ca
PHYSICIAN REFFERAL FORM
Date:
Child’s Name:
Last
First
Middle
Date of Birth (Y/M/D):
Age:
Gender: M or F
Mailing Address: Please include Postal Code
Street:
City:
Prov:
Postal Code:
Main Email Address:
Parent or Legal Guardians:
Mother:
Father:
Last
First
Last
Cell:
Cell:
Home:
Home:
Work:
Work:
First
Family Dr. ___________________________________Pediatrician__________________________
Doctors Phone:
Doctors Email:
District:
School:
Phone:
Grade/Program:
Days child attends school (please circle): M T W R F am pm
Teacher(s): _____________________
PUF? Yes / No
Teacher Assistant: ______________________
Services requested:
Occupational Therapy: 
Physical Therapy: 
SLP: 
Psychology: 
Concerns to be addressed:
________________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please indicate any assessments, therapy or other services provided within the past 2-3 years.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Medical history (Including vision, hearing, health concerns etc.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Additional Comments:
________________________________________________________________________________
________________________________________________________________________________
Consent:
I
give permission for my son/daughter
(please circle one)
to receive services from Function First Pediatrics Inc. The procedures, expected outcomes, and
consequences of intervention or of refusing intervention have been explained to me. I understand
that the information obtained during the assessment/consultation is confidential and will not be
released without my informed written consent. At Function First Pediatrics we do not direct bill
Insurance providers or Alberta Health Care. I understand that all cost associated with Function First
Pediatrics are my sole responsibly to pay.
Release of Information:
I authorize __________________________ to disclose to Function First Pediatrics Inc. any reports
or information required for the purposes of this assessment / treatment.
□ Yes, please send/email a copy of the assessment to the referring Physician’s office.
Date
Signature of Parent or Legal Guardian
Date
Signature of Physician
2
FINANCIAL AGREEMENT
Select the services you are interested in receiving: (someone will contact you to discuss/confirm services)
OT Assessments
□ $500.00
Sensory Assessment
□ $300.00
Fine/Gross Motor Skills Assessment
□ $350.00
Perceptual Assessment
□ $700.00
Full Assessment with Report
□ $150.00
Assessment – No Report
□ $135.00
Other/Intervention/**Travel Time hourly Rate
Psychological Assessments
□ $1800.00 Psycho-Educational Assessment
□ $175.00
Counceling/hr
□ $175.00
**Travel Time/hr
□ $175.00
Other
FEES FOR FOLLOW-UP/HOURLY SERVICES:
Occupational Therapy:
Physiotherapy:
Speech Language Pathology
Psychological Services:
OT/PT/SLP Assistant:
Mileage
Speech & Language Assessments
□ $150.00
Articulation Assessment
□ $400.00
Articulation & Language
□ $200.00
Articulation & Language – No Report
□ $135.00
Other/Intervention/**Travel Time
Physiotherapy/Assessment
□ $135.00
Consult/hr
□ $135.00
**Travel Time/hr
$135.00/hr
$135.00/hr
$135.00/hr
$175.00/hr
$60.00/hr
$0.50/km
Documentation Time charges apply on all direct and indirect time spent on your file. Documentation
Time is charged hourly. Should you require a Formal Report, charges will be applied accordingly
unless otherwise noted (included). Please consult with the therapist regarding the length of time
expected for the Formal Report to be completed.
Clients receiving our services are required to provide us with their credit card number in order to
complete their appointment booking. Clients must provide payment at the end of each visit/session.
Cancellations or rescheduling of appointments must be done at least 24 hours before appointment.
Should you fail to show up to your scheduled appointment there will be a $50 “no show” charge
applied to your credit card. For Out of Town clients a Mileage /Travel Time fee will be added as well
based on rates.
If you are an FSCD Client, you will be responsible and charge Cancellation Fee’s. If you would like
extra hours, you will be responsible to pay the hourly rate.
I ______________________________________ (print name) agree to the above rates and
conditions and will be financially responsible for the costs of this service.
Signature: _________________________________________
Date: ____________________________
Credit Card Type:_________________
Credit Card Number_____________________________________________________________ Expiry MM/YY ______________
Name as it appears on card:_________________________________________________
Forms /Admin/ Financial Agreement form 2014
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