​​Print and bring to medical appointment
 

1. Doctor Referral Form​​ - Bring this form to your next appointment with your pediatrician and ask about whether your child might benefit from an occupational therapy evaluation.

2. Release of Information - Complete this form so that Learning Coach can receive information about your child's medical and developmental history to create effective evaluation and treatment planning.

3. Insurance Verification Form​​ - Submit this form so Learning Coach can contact your insurance carrier and send you an estimate of covered services.​
   
   Read, Sign, and Return
    

4. Learning Coach LLC Practice Policies - Review and understand the policies that allow Learning Coach to deliver effective services.

5. Informed Consent for Occupational Therapy - Review and understand what you need to know about occupational therapy, including its potential risks and benefits.

6. Notice of Privacy Practices - Review how your protected health information (PHI) is used to create effective treatment, as well as your rights to have that information protected.

7. Electronic Communications Policies - Review the most secure methods of exchanging information with Learning Coach, including when you should and should not use email.

8. Credit Card Authorization Form - Ensure that your card used for paying copays or costs not covered by insurance is being used appropriately. ​
   
   Complete, Sign, and Return
    

9. Intake Questionnaire - Submit information that is extremely valuable to evaluation and treatment planning.

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