General Intake Form

Dear New Family,

Welcome to Cutting Edge Pediatric Therapy (CEPT)! We are excited to have the opportunity to assist your child in their therapy care. Our therapists strive to provide the highest quality treatment using the most current and innovative therapy treatments currently available, in a professional and caring manner. We are committed to helping you identify your child’s needs and achieve their goals, while striving to meet our mission, “Therapy with a Purpose”. Our sincerest belief is that every intervention will have a purposeful outcome for all of our clients.

CEPT provides therapy for both children and adults. We specialize in the individualized treatment of each patient and their family structure. Our treatment modalities include Receptive and Expressive Language, Language Processing, Articulation, Phonological Processes, Fluency, Augmentative Communication, Feeding/Swallowing, Craniosacral/Myofacial Release Therapy, Fine and Gross Motor Skills, Functional Activity Training (ADL), OT Intensive Programs, Oral Motor/Feeding Therapy, The Listening Program, TLP/Bone Conduction, Therapeutic Listening Program, and Interactive Metronome. Our therapists specialize in multi-types of treatment techniques for a multitude of systems. CEPT is also a teaching clinic so on occasion students from various colleges may accompany your child’s therapist, observe treatment and have sight of their notes. Please let me, your child’s therapist, or our office staff know if this is a concern for you.

Below is the General Patient Intake Form. Please read the information carefully, fill out all the sections, and return to us at least 2 days prior to your child’s evaluation appointment. Please note that payment is due at the time of the evaluation. We accept cash, checks, Visa, MasterCard, Discover, and American Express. Checks are to be made payable to CEPT. Should you wish to pay by credit card, please have your driver’s license and credit card with you at the time of your appointment. A photo copy of both will be kept on file with your Credit Card Policy Agreement form.

CEPT is an in-network provider with Blue Cross Blue Shield (as well as traditional Medicaid at the Allen location) and files out of network insurance claims with most insurance carriers. At this time, it will be the patient’s responsibility to determine the proper coverage for all other insurance carriers and to contact their insurance company regarding their out-of-network deductible and benefits prior to the appointment. You will need to pay in-full for each appointment and receive reimbursement from your insurance company in accordance with the terms of your contract with them. Once we receive your insurance information, we can schedule your child’s evaluation. Your child’s initial evaluation will last approximately two hours. Your therapist will then schedule a parent meeting to discuss the evaluation and treatment options with you.

I can never effectively communicate our passion and enthusiasm for the innovative ways that we are reaching patients through our treatments here at CEPT.  It is our sincere desire to partner with you and your child as we start this new and exciting journey together.

With kind regards,
Your Cutting Edge Pediatric Therapy Team

1 Patient Intake Information
2 Parent/Guardian Information
3 Insurance Information
4 Medical History / Developmental History
5 Notice of Privacy Practices
6 Financial Agreement
7 Communication Consent Form
8 Clinic Wellness Policy
9 Automatic Credit Card Billing Agreement
10 Clinic Policies
11 Authorization to Transfer Medical Records
  • Patient Intake Information – For All Services