DEMOGRAPHIC INFORMATION

CLIENT INFORMATION -
CLIENT’S NAME:                                                                                         CLIENT’S DATE OF BIRTH:                                        
ADDRESS OF CLIENT:                                                                                CLIENT’S TELE #:                                                         
CITY, STATE, & ZIP CODE OF CLIENT: ZIP CODE:                                                                                                                        
NAME OF PARENTS:                                                                                                                                                                                
IF CLIENT IS A CHILD UNDER AGE 21, MARITAL STATUS OF BIRTH PARENTS:                                                           
WHO HAS CUSTODY? (Attach court documents showing custody)                                                                                       
LIST ANY FAMILY MEMBERS BEING SEEN IN THE PAST OR PRESENT AT TFC?                                                           
PRIMARY LANGUAGE OF CLIENT:         English                 Spanish                 Other:                                                            

REFERRAL SOURCE -
REFERRAL SOURCE:                                                                                 PHYSICIAN’S NPI #:                                                     
REASON FOR REFERRAL:         ____ Evaluation         ____ Therapy         ____ Both

PLEASE ANSWER YES OR NO TO THE FOLLOWING SYMPTOMS -
Check if answer is yes, leave blank if answer is no:
      Delays in Development                    Sensory Processing Problems                            Poor Anger Control
      Meltdowns or Tantrums                  Difficulty with Change or Transitions            Hyperactivity
      Attention Problems                           Trouble with Reading/Writing/Math           Impulsive Behaviors
      Oppositional/Argumentative        Sleep Problems                                                      Social Problems
      Memory Problems                             Poor Fine or Gross Motor Skills                        Dizziness or Confusion

PREVIOUS DIAGNOSES OR SUSPECTED DIAGNOSES (check if answer is yes):
      Autism/Asperger’s                           Developmental Delay                                           ADHD (same as ADD)
      Learning Disorder                             Sensory Processing Disorder                            Bipolar Disorder
      Oppositional Defiant Dis                  Auditory Processing Disorder                         Depression
      Anxiety                                                  Obsessive-Compulsive Dis (OCD)                   Personality Disorder
Other:
                                                                                                                                                                                                           

PRIMARY INSURANCE INFORMATION -
Name of Primary Ins. Co:                                                                                 ID #:                                                                           
Name of Insured:                                                                                                DOB of Insured:                                                     
Insured’s Relationship to Client:                                                                  Insured’s SSN:                                                       
Employer Name:                                                                                                                                                                                      

SECONDARY INSURANCE INFORMATION -
Name of Secondary Ins. Co:                                                                             ID #:                                                                           
Name of Insured:                                                                                                DOB of Insured:                                                     
Insured’s Relationship to Client:                                                                  Insured's SSN:                                                        
Employer Name:                                                                                                                                                                                      
                                             CONSENT TO EXCHANGE INFORMATION


I hereby authorize Dr. Linda L. Thede of the THEDE FAMILY CENTER FOR AUTISM AND
NEURODEVELOPMENTAL DISORDERS to exchange information with the following family members,
teachers, schools, providers, or other entities as of the date signed below. I understand that this
consent will be in force for one year unless I provide a written request for it to cease. I further
understand that this information exchange is solely for the benefit of the client’s personal health and
welfare, and I hereby waive my rights to confidentiality only for the purposes of evaluation and treatment.

Name of Individual or Entity                  Relationship to Client                  Tele. Contact Information

WHOLE KIDS CO. LLC                         Business Associate of                 719/344-9342        
                                                       
     Thede Family Center

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__________________________        ______________________                                                         

__________________________        ______________________        
                                                 

__________________________        ______________________        
                                                 




Signed,


_________________
____________________               ________________________
Client’s Signature (age 12 or over)                        
           Date

___________________
__________________               ________________________
Parent or Guardian of Client                                
             Date

_________________
____________________               ________________________
Psycho
gist's Signature                                                      Date       
            THEDE FAMILY CENTER FOR AUTISM AND NEURODEVELOPMENTAL DISORDERS
                                                                 FEE SCHEDULE

Client Name:________________________________________     Date:
                                               

    Here is a list of my current standard charges for the various services provided by me and the CPT
billing codes for each, and I reserve the right to change these terms at any time without prior
notification. Only if I am in network with your insurance company will I accept their agreed upon rates.
This currently includes Colorado Medicaid, Medicare (Part B but no Advantage Plans or QMB Plans),
and Aetna. I am a certified out-of-network provider through Tricare and accept their rates, as well, but
you may be expected by them to pay me a different copay or deductible amount than you may be
accustomed to for other services. Your insurance may not cover all of your healthcare costs for
various reasons, and you will need to contact them directly to discuss the details of your particular
insurance plan. Some insurance plans limit what they consider to be “covered benefits.” They may also
require that you pay a certain portion as a copay or coinsurance amount, and all providers are
required by law to collect that portion from you. Failure to comply may result in loss of coverage for
you. As such, if you agree to receive services from me, you will be required to pay out of pocket at the
time of service any portion of costs not covered by your insurance company. This includes paying my
full fee if you do not have one of the above-listed insurance providers.
    Following is a list of my current fees which are always due and payable to me upon your arrival at
the time of service:

    Intake Session (CPT 90791)                                                                                                $150.00
    Psychotherapy (CPT 90832, 90834, 90837, 90846, or 90847) (each 30-60 minutes)           140.00
    Integrative Report Writing only (CPT 96132 or 96133)
       Autism Spectrum Evaluations                                                                                              140.00
       Brief Neuropsychological Evaluations                                                                                  280.00
       Full Neuropsychological Evaluations                                                                                   420.00

    Any testing requested by you will be done by my business associates at Whole Kids Co. and
subject to their fees and terms. I will assist them in the final review of test results and interpreting those
results for your final diagnostic report.
    I accept cash, checks, flex-account cards, and most major credit cards. If you choose to use a credit
or flex-account card, please be aware that the bank adds on their own 3-4% processing fee to the
amount due. I do not impose any additional service charges unless you pay by check, and the bank
returns your check for insufficient funds. In that case, you will incur an additional $20 penalty charge
due and payable prior to your next appointment.
    If you are unable to pay at the time of service, your appointment will be rescheduled. I do not
provide monthly billing statements or establish payment plans. You may request a superbill/receipt
from me each time you pay for your records. Sometimes clients are able to get reimbursed from their
insurance provider if they turn in their receipts, but this will depend upon your insurance plan, and you
will need to discuss this possibility with them.  
    By signing below, you are acknowledging that you understand and agree to these terms of service.

                                                                                                                                                                 
Client Signature (if age 12 or over)                                  Date of Signature

                                                                                                                                                                 
Print Name of Parent or Legal Guardian                          Parent/Legal Guardian Signature