MJ KIDZ
1930 Marlton Pike E, A-1
Cherry Hill, NJ 08003
OCCUPATIONAL THERAPY: INTAKE FORM
DATE: ______________________________
COMPLETED BY: ___________________________
CHILD’S NAME: _____________________________________________________________________________
DATE OF BIRTH: ___________________________ PHONE NUMBER: ___________________________
ADDRESS: ____________________________________________________________________________________
CITY: _______________________________________
STATE: _________ ZIP CODE: _______________
PARENT(S)/GUARDIAN(S)
NAME: _______________________________________ CELL: _________________________________________
NAME: _______________________________________ CELL: _________________________________________
EMAIL: ________________________________________________________________________________________
EMERGENCY CONTACT
NAME: _______________________________________ RELATIONSHIP: _____________________________
PHONE NUMBER(S): ________________________________________________________________________
IMPORTANT/BACKGROUND INFORMATION
MEDICAL DIAGNOSES/OTHER DIAGNOSES
PARENTAL CONCERNS/REASON(S) FOR INTAKE/OTHER INFO
OFFICE USE ONLY: ____ CALL BACK ____ SCHEDULED ____ OTHER: ____________________
OTHER INFO:
MJ KIDZ
1930 Marlton Pike E, A-1
Cherry Hill, NJ 08003
RELEASE OF INFORMATION
BY MY SIGNATURE BELOW, I KNOWINGLY AND VOLUNTARILY AUTHORIZE MJ
KIDZ AND EMPLOYEES TO USE, DISCLOSE, AND/OR OBTAIN MEDICAL OR
EDUCATIONAL INFORMATION REGARDING MY CHILD TO/FROM:
_____ SCHOOL DISTRICT/EDUCATIONAL FACILITY
SCHOOL/DISTRICT: _________________________________________________________________________
PHONE: ___________________________________
FAX: _________________________________________
CONTACT(S): ________________________________________________________________________________
EMAIL(S): ____________________________________________________________________________________
NOTES/COMMENTS/OTHER:
_____
MY CHILD’S PEDIATRICIAN
PRACTICE/PHYSICIAN: _____________________________________________________________________
PHONE: ___________________________________
FAX: _________________________________________
EMAIL: ____________________________________________________________________________________
NOTES/COMMENTS/OTHER:
____
OTHER: _____________________________________________________________________________
NAME: _______________________________________________________________________________________
PHONE: ___________________________________
FAX: _________________________________________
EMAIL: ____________________________________________________________________________________
NOTES/COMMENTS/OTHER:
_____________________________________________________________
SIGNATURE
________________________________
DATE
MJ KIDZ
1930 Marlton Pike E, A-1
Cherry Hill, NJ 08003
FINANCIAL RESPONSIBILITY
BY SIGNING BELOW, I AM ACKNOWLEDGING THE FOLLOWING IN REGARDS TO
PAYMENT:
1) PAYMENT IS DUE AT THE TIME SERVICES ARE PROVIDED.
2) PAYMENT MAY BE IN THE FORM OF A CREDIT CARD, HSA CARD, CHECK, OR
CASH.
3) A RECEIPT WILL BE PROVIDED WHEN PAYMENT IS RECEIVED.
4) DOCUMENTATION FOR EACH SESSION WILL BE PROVIDED UPON REQUEST.
5) IF A CHECK BOUNCES, I WILL BE CHARGED AN ADDITIONAL FEE OF $25.00.
6) IF TWO CONSECUTIVE APPOINTMENTS ARE MISSED WITHOUT NOTICE (NO
SHOWS), YOUR CHILD WILL BE REMOVED FROM THE SCHEDULE AND A
$25.00 FEE WILL APPLY.
7) THERE IS NO GUARANTEE OF REIMBURSEMENT FROM MY INSURANCE
COMPANY FOR PRIVATE PAY OR OUT-OF-NETWORK SERVICES.
PLEASE CHOOSE ONE OF THE FOLLOWING:
____
I WILL NOT BE SEEKING REIMBURSEMENT FROM MY INSURANCE
COMPANY.
____
I WOULD LIKE FOR MJ KIDZ TO SUBMIT TO MY INSURANCE COMPANY FOR
OUT-OF-NETWORK BENEFITS IF APPLICABLE.
CHILD’S NAME: ______________________________________________________________________________
I, ________________________________________________________________________________, HAVE
READ, UNDERSTAND, AND AM IN AGREEMENT WITH THE ABOVE STATEMENTS.
PARENT/GUARDIAN SIGNATURE: _________________________________________________________
PARENT/GUARDIAN NAME: _______________________________________ DATE: ________________
PLEASE RETURN ALL FORMS TO:
MJ KIDZ
1930 Marlton Pike E Suite A-4
Cherry Hill, NJ 08003
Fax: (856) 433-8507
Email: MJKidzgroups@gmail.com