1. Intake / Case History Form (Pediatric & Adult)
The intake form allows you to collect information about the client's developmental, educational, vocational, speech/language/cognition/feeding/swallow etc. history. Ideally, you would send this form to the client in advance and have it filled out and returned before their evaluation.
2. HIPAA Notice (aka Notice of Privacy Practices) and Acknowledgement of Receiving HIPAA Privacy Notice
The first sheet clearly states the responsibilities of the private practice, the uses and disclosures of protected health information as well as the patient's rights to privacy. The second sheet is a form for the patient to sign that acknowledges that they have seen the HIPAA notice and understand its contents.
3. Authorization to Exchange, Obtain or Release Information Form
This form allows you to share and receive information with other professionals for evaluation and treatment planning purposes.
4. Consent For Services Form
This form gives permission to the private practitioner to complete an evaluation and render appropriate therapy services.
5. Attendance Agreement / Cancellation Policy
This form clearly outlines the attendance, tardiness, cancellation, bad weather, illness, etc. policies, as well as any fees that the client may be responsible for as a result of a missed session.
6. Screening Permission Form
This form provides consent from parents for you to conduct a screening with their child (to see if they are within normal limits or should be evaluated further).
7. Payment Policy
Detailed form explaining the client's financial responsibility and payment terms including your fees / rates and payment options.
8. Record of Contacts
This form provides a record of phone calls, e-mails, etc. as well as details about the interaction.
9. Attendance Log (optional - with Payment Information)
This form provides a record of all attended sessions as well as who the payor source for the session was and whether the session was paid or if the payment is pending.
10. Insurance Verification Form
This form collects information about the client's health insurance, including their primary insurer, secondary insurer, subscriber number(s), co-pay, etc.
Unfortunately, we live in a litigious society and it's important to have all of your legal bases covered. Having these forms signed by clients will help protect yourself and your private practice in case of a legal battle.
If you're looking for customizable, fillable Word and PDF versions of essential clinic forms for your private practice, click here.
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Jena H. Casbon, MS CCC-SLP is a private practice consultant who helps SLPs, OTs and PTs start their own private practices. She is the author of two books: The Guide to Private Patients and The Guide to Creating a Web Presence For Your Private Practice and an online course, Grow Your Private Practice.