Client Information
Referral Process and Insurance
Patients may be self-referred or referred by physicians, third-party payers, or other health-care professionals. Please contact us if you have specific questions or concerns about the therapy needs of your child. Wild and Free is working to accept most major insurances but are currently accepting patients through private pay at this time.
Pre-authorization and billing of insurance are services provided as a courtesy for patients. New patients are encouraged to complete the information forms located on this page prior to your first therapy session.
Patient Forms
Please complete the new client information forms listed below prior to first session. Please contact the office if you need assistance.
Intake Form
This will supply us with the information we need to get started with your child’s therapy services.
HIPPA Privacy Practice
This describes how medical information about you may be disclosed, and who may access this information
Acknowledgement of Privacy Practice
Please download and sign this form to acknowledge you have received and reviewed a copy of our privacy practices.
Financial Agreement
This form indicates that the client understands and assumes responsibility in paying for services rendered.
Consent for Release of Patient Information
This gives us permission to release records to physician’s offices or other parties at your request.
Photo Release Consent Form
This grants us permission to use a patients photo/video for the use of marketing or research purposes only. Wild and Free takes all steps to ensure these images are used solely for the purposes they are intended.
Sick Child Policy
When your child is sick, his/her performance in therapy is not optimal, and in turn, is less beneficial. Therefore, we have established the following illness exclusion policy which adheres to the Centers for Disease Control and Prevention (CDC) Infection Control guidelines.
Your child must be symptom-free for 24 hours, without the use of medications including Tylenol. Therapy will not occur if your child has exhibited any one of the following symptoms within the last 24 hours:
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Fever of 100º or higher
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Diarrhea (runny, watery or bloody stools)
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Vomiting (twice or more in 24 hours)
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Body rash with fever
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Sore throat with fever and swollen glands
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Severe coughing
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Eye discharge (thick mucus draining from eye, or pink eye)
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Yellowish skin or eyes
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Upper respiratory illness such as bronchitis or influenza
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Chicken pox or Hand, Foot, and Mouth (until all blisters have dried and formed scabs)
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Bacterial infection (Impetigo, Strep Throat, etc.)
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Viral infection
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Any parasitic infestation (Lice, Scabies, etc.)
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Extreme irritability, exhaustion, or continuous crying
In the event that your child is exhibiting any of the above symptoms we ask that you contact your therapist as soon as possible to reschedule your appointment.
If you are unsure regarding your child’s status, please contact your therapist and they will use their discretion in deciding whether therapy should occur as scheduled. In the event you arrive for an appointment and find your child is exhibiting any of the above listed symptoms, we reserve the right to cancel the session and attempt to reschedule for a later date.
Because we work so closely to your child, our concern is not only your child’s health, but also maintaining the health of our staff and other patients. Thank you for adhering to this sick policy.
Attendance and Cancellation Policy
At Wild and Free Pediatric Therapy our goal is to provide quality therapy within a timely manner. In order to do so, we have established a cancellation/no show policy. This policy will help ensure that appointment times are available throughout the day.
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Please contact the clinic or your therapist before 9:00 am the morning of your appointment if you need to cancel/reschedule due to illness or emergency.
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Please provide at least 24 hours notice of a cancellation for a planned absence.
We understand there will be times when your child is sick or other unavoidable events will prevent you from keeping your regularly scheduled therapy appointment. If this occurs, we ask that you contact your therapist as soon as possible so they have the opportunity to reschedule the missed appointment and fill your child’s time slot with another appointment. Our therapists will do whatever they can to be available to your child and accommodate your family’s schedule when making appointments. It is expected, in turn, that you will schedule appointments in good faith and facilitate adequate time in your schedule to keep your child’s therapy a priority.
If the clinic or therapist is not informed before 9:00 for illness (unless your child develops symptoms of fever, vomiting, or diarrhea and has to be picked up from school)
or at least 24 hours before a planned absence then the visit will be considered a “NO-SHOW”. A NO-SHOW status is defined as a patient who has failed to be present at the time of their scheduled appointment. Wild and Free Pediatric Therapy will follow a 3 strike rule for NO-SHOW within a 6 month period. After 3 NO-SHOW appointments you may be taken off the therapy schedule. In addition, patients with less than 75% attendance to scheduled appointments will be removed from standing appointment spots.
Pick up Policy If you need to leave during your child’s scheduled therapy time, you must arrive 10 minutes before the end of the session. Please confirm with the therapists your expected return time at the beginning of the session. After 2 late returns, you will not be able to leave the premises during your child’s therapy session.
The intent of these policy’s is to prevent delays in care and utilize therapist time more efficiently by reducing unused appointment slots. Wild and Free Pediatric Therapy reserves the right to charge $25.00 for any appointments that are considered a NO-SHOW or late cancellation. An invoice for the missed appointment will be sent out and payment is due upon receipt if card is not on file. We appreciate your attention to our attendance and cancellation policy, and request that you comply with all cancellations in a timely manner. Thank you for your cooperation!