Updated for 2017!
***These are CHILD forms in DOCX format only; see my store for PDF fillable forms and ADULT forms!***
Description: A collection of 16 forms created for use in my pediatric private practice. These forms took hours to perfect! Each form has fully customizable information for your own practice. The Header includes an area to insert your logo and contact information, as well as a small table to insert client details (e.g., ID number). The forms match in “style” to ensure a professional image for your practice.
NOTE: These forms are in DOCX format and are intended for hard-copy use. I personally save the forms in PDF format with Adobe Acrobat Professional and create fillable forms to share with clients. PDF forms are also available! To order PDF FILLABLE FORMS, check out the listing:
Download the preview file for a FREE FORM!
1. Child Intake Form: 4 pages; collect detailed information about the child’s birth history, health, development, feeding behaviors, and more.
2. Consent for Release of Information: 1 page; get consent to share and receive information.
3. Contact Log: 2 pages; keep detailed notes regarding every phone call and email for your clients.
4. Data Collection: 2 pages; the Word version of my free data collection sheet (available as free PDF file in my store). Fully customizable!
5. Free Screening: 1 page; offer free screenings to local schools to boost your referrals.
6. Notice of Privacy Practices: 2 pages; inform your clients of standard privacy practices based on the form provided by ASHA in June 2014.
7. Payment Policy: 2 pages; a detailed form explaining insurance terms, forms of payment, and cancellations.
8. Progress Notes: 2 pages; SOAP notes for each session, including Date, CPT code, Duration, and Setting.
9. Progress Report: 2 pages; a detailed template for reporting your client’s progress in therapy, including an area for parents to provide feedback about goals, sessions, and services.
10. Referral to Physician: 1 page; send a professional referral to other healthcare providers.
11. Screening & Evaluation Consent: 1 page; a bulleted description of the differences between screening and evaluation, with areas for parent to list concerns.
12. Screening Results: 1 page; a concise results page with recommendations for follow up.
13. Session Location: 1 page; do you provide services in more than one location? Parents can provide detailed information (and consent) to visit their children in various settings.
14. Session Log: 1 page; a full calendar year. Enter the number of minutes for each date, check off whether session notes were completed, and add invoice numbers and payment status. Current year will be uploaded for free--all buyers will receive an email notice when available for download.
15. SLP Intake Form: 1 page; this form is intended to be completed by the SLP during referral phone calls or in person. (FREE IN PREVIEW FILE)
16. Treatment Plan & Goals: 2 pages; a detailed template for creating the treatment plan and goals, including areas for diagnoses, evaluation dates, target area / CPT code, long-term and short-term goals, duration, and prognosis. At the end of the form, there is an area to describe the disorder and information about reviewing progress.
Created by Kate Shepard, Ph.D., CCC-SLP
Clinical Director, Speech-Language Pathologist, and Developmental Psychologist at Shadow Me Speech Therapy