Intake Form

Step 1 of 6 - Contact

16%

Child's Name(Required)

First Last

DOB:(Required)

MM slash DD slash YYYY

Parent/Guardian 1 First & Last Name:(Required)

First Last

Parent/Guardian 1 Phone #:(Required)

Parent/Guardian 1 Email:(Required)

Enter Email Confirm Email

2nd Parent Information

Add 2nd Parent Information

Parent/Guardian 2 First & Last Name:

First Last

Parent/Guardian 2 Phone #:

Parent/Guardian 2 Email:

Child(ren) lives with:(Required)

Both Parents

Parent 1

Parent 2

Guardian

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of School:(Required)

School District(Required)

Home Language(Required)

2nd Language: if none, enter none

Pediatrician/Clinic Name:(Required)

Pediatrician/Clinic Phone Number:(Required)

Birth Hospital(Required)

What was the length of mother’s pregnancy? ______ weeks(Required)

Any problems during pregnancy or delivery?(Required)

Yes

If yes, please explain(Required)

Following the birth, did your child pass their newborn hearing screening?(Required)

Yes

NICU Stay?(Required)

Yes

Oxygen?(Required)

Yes

IV Antibiotics(Required)

Yes

High Bilirubin?(Required)

Yes

Other Medical history/hospitalizations:

Any problems with ear infections?(Required)

Yes

Any ear infections in the last year?(Required)

Yes

Does your child have ear (PE) tubes?(Required)

Yes

If yes, then when did your child received it

Has your child had a hearing screening?(Required)

Yes

If Yes, What were the results:(Required)

If no, explain

Have you, any family members, teachers, or physicians been concerned about a medical, developmental, psychological, language, motor, or other problems with your child?(Required)

Yes

If Yes. Explain:(Required)

Family history of hearing loss?(Required)

Yes

If yes, family member’s relationship:(Required)

Mother

Father

Sibling

Family Member

None

Unknown

My child has been diagnosed with another disability/syndrome other than hearing loss?(Required)

Yes

Suspected

Anything else you would like us to know about your child’s medical history:

Check all the ways your child currently communicates wants and needs:(Required)

Crying

Uses Playful Sounds

Points with index finger

Gestures

Words

Phrases

Sentences

Sign Language

None

Your Child(Required)

Reacts to Loud Sounds

Reacts to voice

Initiates singing familiar songs

Enjoys group story time

Notices environmental sounds

Imitates Sounds

Responds to spoken language

None

Your Child:(Required)

Enjoys looking at books

Uses single words, Responds to “yes/no” questions

Understands names for common objects

Answers simple questions

Uses words for feelings

Uses words, phrases and sentences

Has conversations with multiple turns

None

Were your child’s developmental milestones met at the appropriate age?(Required)

Yes

Unsure

If no, please explain:(Required)

Parent/Guardian(s) Name:(Required)

First Last

Phone number:(Required)

Parent/Guardian email:(Required)

Enter Email Confirm Email

Pediatrician/Clinic Name:(Required)

Pediatrician/Clinic Phone Number:(Required)

Information may be obtained/requested from or sent to (list any/all that apply):

Audiologist:

School District

Pediatrician:

Regional Center:

Other

Consent(Required)

I agree to the privacy policy.

• I grant permission for John Tracy Center to obtain or discuss medical, audiological, developmental and/or educational data which will
assist John Tracy Center in its services to my child.
• I understand that the information contained in John Tracy Center reports may be transmitted by JTC to educational and/or medical
agencies and individuals, in cases where exchange of information will be beneficial for my child.
• I understand that John Tracy Center preserves the confidentiality of information in accordance with statelaw.
• This authorization is effective immediately.
• I understand that I may revoke this authorization in writing at any time.
• This authorization shall terminate when my child exits services with John Tracy Center.
• JTC will no longer be authorized to disclose information and records after that time without my consent.
• Photocopies/facsimile copies of this authorization shall be considered as valid asthe original.
• I further understand that I have a right to receive a copy of this authorization upon my request.

Parent/Guardian Signature:(Required)

Date(Required)

MM slash DD slash YYYY

HIPPA Consent(Required)

I agree to the HIPPA Consent

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me and my
child under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I
authorize you to use and disclose my child’s protected health information to carry out:
• Treatment (including direct or indirect treatment by other healthcare providers involved inmy treatment);
• Obtaining payment from third party payers (i.e., my insurancecompany);
• The day-to-day healthcare operations of thepractice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains
a more complete description of the uses and disclosures of my and my child’s protected health information and our rights
under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may
contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how our protected health information is used and disclosedto carry
out treatment, payment, and health care operations, but that you are not required to agree to these requestedrestrictions.
However, if you do agree, you are then bound to comply with the restrictions.
I understand that I may revoke this cons

CAPTCHA

Parent/Guardian Signature:(Required)

Date(Required)

MM slash DD slash YYYY

{all_fields}