Myofunctional Therapy Information (Child) Step 1 of 6 - Welcome Packet 0% Welcome Packet Welcome to San Diego Center For Speech Therapy, Myofunctional Therapy, Occupational Therapy, & Educational Services. We are delighted that you have chosen us to be the providers of your therapy. This packet must be entirely completed and submitted electronically to us before any services are scheduled. You are able to hit "save" and complete filling out this form at a later time, but the form will NOT be sent to us until you complete it entirely and hit "submit" at the end of the form. It is estimated that this form will take you about 20 minutes to complete. If for any reason you are not able to easily access this online form, please contact out office ASAP, and we can email you a PDF version or send you a hard copy that you can fax/email back to us before your appointment. This packet contains the following documents: 1. General Information with details about our clinics. 2. New Patient Information Form in order for us to get details about your child. Please type your answers onto this form. Our Speech-Language Pathologists, Myofunctional Therapists, Occupational Therapists, and Educational Specialists at SDCST think of our jobs as a detective-work, decoding the specific strengths and weaknesses of our clients and building strategies to overcome those weaknesses to help the children ultimately reach their highest potential. We appreciate your thoroughness in answering all of the questions on the Information Form! 3. Authorization To Exchange Information Form to allow us to contact your child’s school, teacher, pediatrician, psychologist, dentist, orthodontist, or any other specialists that may pertain to our therapy and your child’s progress. Please electronically sign the bottom of this form. 4. Photo/Video Permission Form We will take pictures of your child as baseline measures and to show progress in therapy. You additionally have the option to allow us to potentially use a photograph/video on our website, brochures, or during educational lectures to other related professionals so other patients and professionals are able to see the progress that our clients make in therapy. We appreciate your permission, as this helps others understand how truly beneficial speech therapy, myofunctional therapy, and OT really are. Please check the appropriate boxes and electronically sign the bottom of this form. 5. Credit Card Authorization Section to be used for all payments. Please contact our office manager at 858-488-4810 to provide her with your entire credit card number. As part of our general procedures, your credit card will automatically be charged after every session or the next business day. Your credit card information given to our office manager is secure and confidential. We will need some basic credit card information verified on this form, including the last 4 digits of your credit card. Please do not forget to electronically sign this form, as you must complete this form for any sessions to occur. We will need your credit card information to hold your place for sessions. You will not be able to submit this packet without signing. For SD Regional Center patients, we need your credit card information as part of our cancellation policy as well. We currently accept Visa and Mastercard. Save and Finish Later General Information, Policies, & Procedures Information Form Please complete the Information Form on the following pages as soon as possible and as detailed as possible so we are able to start your child's file. There is no need to print this form out. Please enter information directly onto this form from your computer, and when you have completed the form in its entirety and hit "submit", it will be emailed to our office. Other Documents Relevant To Your Child Please fax (858) 746-4113 or email Info@SanDiegoCenterForSpeechTherapy.com us a copy of any prior Speech/Language, OT, PT, Psychological, dental/orthodontic evaluations or reports (including IEPs or any other pertinent reports) that your child has had. This will be important for us to receive before we begin our speech/language, myofunctional, OT, or academic evaluation or therapy. Office Locations We have two offices, one in Carmel Valley and one in Liberty Station / Point Loma. Carmel Valley Office Our address in Carmel Valley is: 12707 High Bluff Drive, Suite 200 (inside Regus) San Diego, CA 92130. Directions are on the website. When you enter our Suite #200, you can check in with the receptionist. If the receptionist is not in, your therapist will come out to the waiting room to greet you at the time scheduled for your session. If you have any children with you, please have them wait in our waiting room. Liberty Station / Point Loma Office Our address in Liberty Station is: 2305 Historic Decatur Road Suite #100, San Diego, 92106. This is our satellite office that focuses on Myofunctional Therapy. When you enter the office, please wait in the waiting room and your therapist will come to get you at the start of your appointment time. We typically have parents/caregivers in the room during our myofunctional therapy sessions. Payment Payment for all sessions is expected via your credit card that will be kept securely on file. For convenience, your credit card will automatically be charged by our office after the session or the next business day. If you have any questions about payments/finances, please contact our Office Manager, at (858) 488-4810 or email Info@SanDiegoCenterForSpeechTherapy.com. Please do not discuss any payment questions with the therapist, as our therapists are solely responsible for the care and treatment of you. Also, if your child receives our services through San Diego Regional Center (SDRC) and you would like to continue speech or occupational therapy with us after your child’s SDRC services expire, you must pay privately, on your own accord, for our services. Cancellation Policy We have a 24 hour cancellation policy. If you ever need to cancel/change your session, please call us at least 24 hours in advance. You may call our office manager at (858) 488-4810 to cancel a session. A phone call is the quickest and most efficient way to cancel a session. The fee for a no-show or cancellation of an evaluation with less than 24 hour notice is $100.00. There is a charge of 100% of the session fee for any therapy session cancellations less than 24 hours or no shows. This cancellation fee also applies to SD Regional Center clients. The time slot that you have chosen for your child is reserved solely for your child. We do not double-book patients and are unable to add a patient who is on our waiting list to a cancelled session when we are given less than 24 hours notice. We may need to remove your child from our schedule if there are more than 3 cancellations that are less than 24 hours. IF WE WORK WITH YOUR CHILD AT HIS/HER SCHOL SITE, IT IS YOUR RESPONSIBILITY TO INFORM US IF YOUR CHILD IS ABSENT FROM SCHOOL OR WILL EVER BE MISSING HIS/HER THERAPY SESSION(S) FOR ANY REASON, AS OUR CANCELLATION RATE STILL APPLIES. We thank you for your understanding of our cancellation policy. Insurance Questions and/or Receipts San Diego Center For Speech Therapy is not an in-network provider, meaning that we do not accept insurance and we are considered "out of network" for insurance companies. You are expected to pay us in full for each session. However, we are able to provide you with an insurance receipt ("Superbill") that has the insurance codes for your sessions. You can then submit this Superbill to your insurance on your own accord to seek reimbursement according to your "out of network" benefits. Please let our office manager know if you would like her to send you the Superbills, and she can do so on a monthly basis. A referral from a physician (and/or dentist or orthodontist for orofacial myology/myofunctional therapy) can be included from you when you mail the Superbill to your insurance, as this sometimes helps with reimbursement. Also, we are "active out of network" providers for TriWest/United Healthcare, meaning that they may reimburse you 50%-100% of session fees. You must contact them for details and to seek reimbursement. In addition, although we are not in-network with insurance, many insurance companies will apply a portion of your payment to your healthcare deductible. Please contact your insurance company for details. We are not responsible for working with insurance companies or for any insurance reimbursements to you. Save and Finish Later New Patient InformationWe thank you for taking the time to complete this form in order to help us get to know your child bettter!Contact & Background InformationChild's Name* First Last Date of Birth* MM DD YYYY Today's Date* MM DD YYYY Age*Parents*NameOccupation SiblingsNameAge Home Phone*Mobile PhoneEmail Address* Enter Email Confirm Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country What is the best way to contact you?*Home PhoneMobile PhoneE-mailSchoolGradeReferral Source: How did you hear of us?* Google Yahoo Yelp Pediatrician Dentist Orthodontist Other medical professional Friend Brochure/Newsletter Other Referral Source: Please list the specific physician who referred you, friend who told you about us, or the location where you saw our information/brochure/newsletter. If other, please describe:*We appreciate you letting us know how you heard of us!Do we have your permission to thank the referral source who sent you to us?*YesNoChild's Pediatrician's Name* First Last Child's Dentist's Name* First Last Does your child have an orthodontist?*YesNoChild's Orthodontist's Name* First Last Save and Finish Later Parent ConcernsParent Concerns (Check any that apply)* Speech Articulation- FOR EXAMPLE: Speech Sounds, Child is Hard to Understand, Lisp, Speech Sound Errors, Says Sounds Wrong, Talks too Fast, Mumbles, Slurred Speech, Unclear Speech, Apraxia, Motor Planning, Phonological Impairments Delayed Talker- FOR EXAMPLE: Barely Talking, Not Talking Yet, Language Delayed Receptive Language Challenges- FOR EXAMPLE: Comprehension Issues, Auditory Processing Challenges, Does Not Understand What is Said, Cannot Follow Directions Well, Poor Listening Skills Expressive Language Challenges- FOR EXAMPLE: Grammar Issues, Sentences Not Correct, Hard Time Telling A Story, Hard Time Expressing Oneself Reading Challenges- FOR EXAMPLE: Dyslexia, Hard Time Sounding Out or Decoding Words Social Skills- FOR EXAMPLE: Pragmatics, Eye Contact, Hard Time Making Friends, Off Topic, Hard Time Initiating With Peers, Inappropriate with Peers Stutters- FOR EXAMPLE: Repeats sounds and words Voice Sounds Different FOR EXAMPLE: (hoarse, raspy, pitch is off, etc.) Orofacial Myofunctional or Tongue Thrust (separate or in addition to speech sound errors)-FOR EXAMPLE: Mouth Is Open At Rest, Lips Rest Apart, Tongue Sticks Forward Throughout The Day, Sucks Thumb/Fingers/Objects, Chews Nails, Swallowing and Eating Challenges, Orofacial Myology, Myofunctional Therapy, Dentist/Orthodontist Has Concerns, Dental Issues, Sleep-Related Breathing Issues (snoring, sleep apnea) Feeding Challenges-FOR EXAMPLE: challenges with feeding skills including issues with current diet, limited food intake, limited intake of a variety of foods and textures, mealtime routines/patterns, limited intake volumes, and behaviors at meals, difficulty with chewing, manipulating food in the mouth, or swallowing, oral-sensory challenges with feeding that impacts your child's ability to accept new foods including vision, smell, touch, and taste. Occupational Therapy Related Challenges-FOR EXAMPLE: fine motor issues, challenges with tool use (using a pencil, crayons, scissors, utensils), challenges with dressing (buttons, zippers, snaps, shoe tying), gross motor difficulties (walking, running, ball play, stair use, climbing, play structure), sensory challenges (including sensory difficulties using play doh, sand, glue, water, issues with physical contact with peers and adults) Other If "Other", please explain.*Please describe in detail your specific speech/language/orofacial-myofunctional, occupational therapy, or academic related concerns with your child.*In terms of your child’s development, what would you like your child to be able to do that he/she is not doing now?.*Please list a few of your child’s strengths and likes/areas of interest.*Please list a few of your child’s weaknesses.*Prior TherapyHas your child had a speech/language/orofacial-myofunctional or occupational therapy ASSESSMENT before?*NoYes*WhereWhen Please describe the results*Has your child ever received speech, myofunctional, or occupational THERAPY before?*NoYes*WhereWhen Is your child currently receiving speech, myofunctional, or occupational THERAPY?*NoYes*WhereWhen If your child currently or in the past has had speech therapy, myofunctional therapy, or occupational therapy, please describe what was addressed in the therapy.*Does your child receive any special education services in school (e.g., speech therapy, OT, APE, special day class, resource support, learning center)?*NoYesServices on IEP* Speech OT Learning Center/Resource/Academic/Special Day Class APE N/A Developmental HistoryAre you the biological parent(s) of your child?*NoYesPlease list any known information on the child’s biological mother, her pregnancy, your child’s birth history and development (age appropriate developmental milestones?) as well as any information on the biological father. Please also describe where the child resided before he/she was adopted.*Please describe your child’s birth history. Were there any pre-birth problems, injuries, drug use? Were there any complications during the birthing process?*Was your child breast-fed?*NoYesFor how long (ages)?*Were there any of the following difficulties when breastfeeding?*Check all that apply Latch difficulties Baby made a clicking sound Milk came out of the baby's nose Baby had difficulty staying awake when nursing Reflux or discomfort during or after nursing Baby had colic Mastitis in mother Cracked or sore nipples in mother Thrush in mother or child None Was your child bottle-fed?*NoYesFor how long (ages)?*Did/does your child use a pacifier?*NoYesFor how long (ages and at what times)?*Has your child used a sippy cup?*NoYesFor how long (ages)?*Does your child drool or have a history of drooling?*NoYesFor how long (ages)?*Has your child sucked his/her thumb or fingers before?*NoYesWhat ages? How often?*Has your child sucked on any other items such as clothes, blankets, stuffed animals, pencils, other objects, lips, cheeks, tongue before? Any nail biting? Please list if any of these habits are still occurring or when they stopped.*Did/do you have any concerns with your child reaching his/her developmental milestones (motor skills, speech skills, social interactions, etc.)?*Is there any family history of speech, language, oral-motor, feeding, and/or fine or gross motor difficulties?*NoYesPlease describe.*Health & Medical InformationHas your child suffered any injuries or trauma?*NoYesPlease describe.*Has your child ever had any surgeries or hospitalizations?*NoYesPlease describe.*When and where was your child’s hearing last tested? Please state what the results were?*Does your child have any allergies?*NoYesPlease list and describe.*Has your child ever been tested for allergies?*NoYesHas your child ever been to an ENT (ear, nose, and throat doctor) or an Otolaryngologist?*NoYesDescribe why he/she went to the ENT and the results.*Is your child on any medication?*NoYesPlease list and describe.*Has your child had recurrent issues with any of the following:*Check all that apply Ear infections Tonsillitis Strep throat Gastro-intestinal issues Asthma Other: None Describe your child’s health. Does your child get sick often? List if any of the above are/were recurrent issues:*Sleep BreathingDoes your child snore at all?*NoYesIf yes, please describe how often. Does the snoring wake your child up?*How would you describe your child's sleep behaviors and alertness throughout the day?*Check all that apply Good sleeper Restless sleeper, tosses and turns, or bed is a mess when wakes up Tired upon waking Tires easily Hyperactive or excessive movement and energy Moody throughout the day Other: No concerns/issues with alertness or behaviors How long has your child been snoring or have had sleep apnea?*Do you know what started the sleep-disordered breathing issues? Describe.*Has your child had any treatment for the sleep-disordered breathing issues? Please describe.*Do your child snore with his/her lips:*Check all that apply Open Closed Both Unknown Does your child snore on his/her:*Check all that apply Back Stomach Side Unknown Do you know if your child stops breathing when he/she is snoring?*NoYesHow many hours of sleep on average does your child get each night?*Is your child a restless sleeper (tosses and turns, bed is a mess when he/she wakes up, etc.). Please describe?*Does your child kick or have leg or arm jerks at night while sleeping?*Does your child sweat during sleep?*NoYesDoes your child wake up tired?*NoYesDoes your child fall asleep during the day or appear hyperactive throughout the day? Please describe.*Does your child take naps during the day? If yes, how many naps/day and how long is each nap on average?*Does your child breathe through his/her nose while sleeping?*NoYesAre your child's lips closed when sleeping?*NoYesDo your child have trouble breathing through his/her nose?*NoYesDoes your child have:*Check all that apply Allergies Asthma Frequent colds Excess mucous, congestion No respiratory or congestions issues Do your child have his/her tonsils?*NoYesDo your child have his/her adenoids?*NoYesIs your child taking any medication for breathing?*NoYesList the medication(s) for breathing:*Has your child had any surgery in his/her nose, throat, or mouth?*What time does your child eat dinner?*Would you consider this a large meal?*NoYesDoes your child snack after dinner?*NoYesDoes your child have acid reflux?*NoYesDoes your child take medication for reflux? Do you manage the acid reflux in any other way?*Does your child have a retainer, mouthguard, or any snoring appliance? If yes, how often does he/she wear it?*Feeding InformationPlease describe your child’s feeding history. Were there any feeding difficulties?*Does your child have any current food restrictions or sensitivities/avoidances?*NoYesPlease list and describe.*Do you have any feeding concerns with your child that may be causing you to seek feeding therapy with us?*NoYesPlease list and describe.*Has your child ever had a feeding tube or does your child currently have a feeding tube?*YesNoList feeding schedule and amounts:*How have you attempted to address your child's feeding difficulties so far?*At what age did your child transition to the following foods:PureesDissolvable solidsMashed solidsMixed texturesCrunchy solidsFinger foodsWhat consistency of foods/liquids does your child currently eat? regular liquids thickened liquids (thickener is added or pre-thickened liquid) smooth foods/purees (yogurt, pudding) thick or semi-thick purees (mashed potatoes) chunky purees soft solids (spaghetti, casseroles, macaroni/cheese) dissolvable solids (Gerber puffs, cheese puffs, snap pea crisps) crunchy foods (crackers, chips, pretzels) mashed table foods (fork mashed) regular table foods Approximately how much food does your child eat at each meal?How long does each meal take approximately?What are some of your child’s favorite foods?What foods will your child not eat?How much milk/formula does your child drink at each meal?Does your child drink juice? If yes, how much in one day? Is the juice given before, during, or after a meal?When is your child offered the cup/bottle of formula or milk: during meals, between meals, or all the time?How many times per day does your child eat?Does your child snack between meals? If yes, with what foods?Where does your child eat and how is he/she positioned?Does your child feed himself/herself? If yes, using what?Who is present for meals?Does your child exhibit the following behaviors during meals? Please check all that apply: crying gagging vomiting holding food in his/her mouth spitting food out verbally refusing food getting down from the table during the meal Do you think your child has any difficulty with chewing or swallowing foods (other than refusal)? If yes, please describe.What are your family routines, traditions, and preferences for mealtimes?What you would like your child to be doing at mealtimes? What foods would you like your child to eat?Please describe any other feeding problems your child is experiencing.Dental DevelopmentDoes your child have any orthodontia or history of (e.g., braces, palatal expander, etc.)?*NoYesPlease describe specifically what appliances and when:*Has your child's dentist or orthodontist ever commented that he/she may need orthodontia?*NoYesPlease describe:*Does your child clench or grind his/her teeth?*NoYesIf yes, describe when (day, night, what circumstances) there is clenching or grinding. If you are seeking therapy with us to treat the clenching/grinding, there are more detailed questions in the Bruxim section toward the end of this document:*How would you describe your child's overall dental health?*GoodFair/AveragePoorMyofunctional Therapy QuestionnaireWas your child referred to us for Myofunctional Therapy, AND/OR was your child referred to us by a dentist/orthodontist or other medical specialist for myofunctional/dental/orthodontic/sleep-breathing issues, AND/OR does your child have any of the following behaviors/issues: tongue thrust, sit with his/her mouth open, clenching/grinding, have a lisp, sit with the tongue between the teeth, jaw pain, consistent snoring/apnea/sleep-related breathing issues, or have he/she had braces or orthodontics that have not worked?*NoYesWhat kind of water bottle does your child use? Please describe. Is it a free flowing water bottle or one in which he/she has to suck (with a spout, straw, sucking cap, Camelback, etc.)?*Does your child know how to blow his/her nose well?*NoYesThe following questions will require you to ask your child or for you to observe in your child as he/she is eating, drinking and also relaxing. If your child is able to think about and answer these questions and/or if you are able to observe these behaviors in your child, this will greatly assist in our assessment.When you swallow saliva, do your lips squeeze tight together?*NoYesWhen you swallow saliva, does your tongue come forward?*NoYesWhen you swallow saliva, do the sides of your tongue go between your back teeth?*NoYesDo your teeth close when you swallow saliva?*NoYesWhen eating, do you chew on one side more than the other?*NoYesDo you chew with your lips open?*NoYesDoes your tongue move forward or down when you chew?*NoYesDo the sides of your tongue push between the back teeth when you chew?*NoYesAfter chewing, does the tongue push forward, down, or sideways when you swallow?*NoYesWhen drinking, does your tongue touch the rim of the glass, bottle, or can?*NoYesWhen drinking, does your tongue push forward, down, or sideways when you swallow?*NoYesWhen drinking, do you choke or cough after you swallow?*NoYesAt rest, are your lips parted during the day and/or night?*NoYesDo you breathe through your mouth at rest?*NoYesDo you snore?*NoYesWhen you close your lips, does your chin muscle look bumpy or tight?*NoYesWhere does your tongue rest?* On the floor of the mouth On the teeth Between the teeth Up on the roof Other If your tongue rests in a position other than above, please describe:*Does your tongue feel too large for your mouth?*NoYesDo you have any of the following speech issues:*Check all that apply "Lazy speech" Mumble Trip over your words Issues with particular sounds Other None If you have any other speech issues, please describe:*Does your jaw do any of the following:*Check all that apply Click Pop Make any noises Get stuck in the open or closed position Other None If your jaw has any other issues, please describe:*Have you ever had any jaw trauma or injuries?*NoYesIf you have had any jaw trauma or injuries, please describe the incident(s) and what treatment you received.*Do you have any pain in your jaw, temples, or face?*YesNoBruxism: Clenching or Grinding InformationDoes your child have issues with bruxism (clenching or grinding of the teeth) during the day and/or night?*NoYesAre you seeking treatment for the bruxism (clenching/grinding) with us?*NoYesBruxism: Clenching/GrindingBruxism is defined as the rhythmic or spasmodic grinding or clenching of the teeth in other than chewing movements of the mandible/lower jaw, both at night and during the day. There is no one cause for clenching and grinding. Bruxism has multiple causative factors which the following questions will attempt to uncover. Please ask your child the following or answer the following questions for your child.Do you eat:*Check all that apply Breakfast Lunch Snack Dinner Dessert What time do you typically eat dinner?*What do you typically eat for dessert?*What time do you eat dessert?*Do you drink anything with caffeine?*How often do you drink caffeine?*Do you drink water?*Do you exercise or participate in sports in the evening?*NoYesWhat do you typically do in the evening before bed?*Do you unwind in the evening or wind up?*What time do you go to sleep?*How long does it take you to fall asleep?*When you sleep, do you:*Check all that apply Dream Have nightmares Walk in your sleep Talk in Other None Are there any other sleep behaviors that you may have?*Do you wake in the night?*NoYesHow many times?*Do you know what wakes you?*Are you aware of any clenching/grinding when you wake in the night?*NoYesCan you go back to sleep?*NoYesHow long does it take you to go back to sleep?*Are you a restless sleeper?*NoYesHow often do you get up at night?*What time do you wake up?*What wakes you?*Do you have pain anywhere in your body?*NoYesHow do you manage pain?*Check all that apply Medication Massage Heat/Ice Specialist Other Please describe any other ways you manage pain?*Do you have any medical conditions?*Are you taking any medications?*Do you breathe through your mouth while sleeping?*NoYesWhen sleeping, do you:*Check all that apply Snore Have heavy breathing Have sleep apnea Other None Please describe any other sleep-breathing related behaviors you may experience:*Do you have a night guard or any breathing device?*NoYesDo you currently have any orthodontic appliances?*Check all that apply Retainer Braces Palatal expander Head gear None Other Please list and describe any past or current orthodontic appliances:*What noises might you hear during the night?*Check all that apply Paper delivery Cars Planes Animals Music Phone TV Family members Neighbors Appliances Alarm clock Overhead fan Heater Air conditioner Sibling Other None Please list any other noises you hear at night?*Do you fall asleep to music or TV?*NoYesDoes the phone ring at night?*NoYesDo you sleep alone?*NoYesDo you have any pets in your room?*NoYesDoes a dog or cat sleep with you?*NoYesIs the temperature of your room comfortable?*NoYesIs your bed or pillow comfortable?*NoYesIs there plenty of room in your bed?*NoYesDo you sleep on your stomach?*NoYesDo you have darkening window coverings in your bedroom?*NoYesIs there any light in your room while you are sleeping?*Check all that apply Bedroom light TV Computer Phone/iPad Clock Bathroom light Moon Security light Street/car lights Sun Phone charger Night light None Other Please list any other light that may be entering your room at night that you are aware of:*Are you aware of anything that is not on this questionnaire that disturbs your sleep?*NoYesAre you aware of clenching or grinding your teeth while awake?*NoYesWhen your mouth is at rest, are your teeth:*ApartTogetherDo you notice clenching or grinding anytime in particular during the day?*Check all that apply Car School Angry Upset In pain Tired Late afternoon Hungry Family Other None Please describe any other particular times you may clench or grind your teeth:*During the day, do you breathe through your nose or mouth?*Do you have any:*Check all that apply Allergies Deviated septum Asthma Nasal Congestion Other breathing problems None Please describe any other breathing problems you have:*Do you take any medication for breathing problems?*What stresses are in your life?*Do you feel that stress or anxiety contributes to the clenching or grinding?*NoYes Save and Finish Later Before you complete this form, is there any other information we should know about your child?*Please mail any copies of reports, assessments, IEPs, or any other pertinent information to: SDCST 12625 High Bluff Drive Suite #105, San Diego, CA 92130 OR you may fax the documents to: 858-746-4113 OR you may email the documents to us Save and Finish Later Policies & ProceduresPlease check the box showing that you have read the Policies & Procedures.*Check all that apply Please check the following box that you have read the office Policies & Procedures on page 2: Authorization For Exchange of InformationI give permission to San Diego Center For Speech Therapy to provide information, findings, and records to the referring specialist and any other specialists regarding the care and treatment of this case (please also sign below).*I agreeI do not agreePlease add any specific requests, restrictions, or comments if you wish.Electronic Signature*By typing your name here you are agreeing to the above terms. This field is equivalent to a hand-written signature.Photo/Video PermissionWe take photographs and/or videos as baseline measures and to document patient progress for each specific patient within his/her file. This is a necessary part of the therapy process. The therapists at SDCST function as a team, consulting with one another in order to provide the best services available to you. We share photo/video information amongst our team of therapists confidentially. Please respond below regarding your approval for us to share pictures/videos of your child's progress on marketing materials so other families see the benefits of therapy and also for educational purposes for related professionals.1. I approve for photographs and/or videotapes of myself/patient during therapy to be used on the San Diego Center For Speech Therapy website, brochures, or marketing materials to show progress and the positive results of therapy.*YesNo2. I approve for photographs and/or videotapes of myself/patient during therapy to be used for lectures or continuing education for related professionals to educate them about the benefits of myofunctional therapy, as well as show progress and the positive results of therapy*YesNoPlease add any specific requests or comments if you wish.Electronic Signature*By typing your name here you are agreeing to the above terms. This field is equivalent to a hand-written signature.Credit Card AuthorizationWe are asking that you pay for all therapy sessions via credit card. Your credit card is stored in our secure system, and our office will automatically charge your credit card on file after any therapy services. By completing this form, you acknowledge that you understand and agree that you are responsible for any evaluation payments, session payments, or no-show and cancellation charges due at the time of service, and SDCST may apply the charges to the credit card indicated. You also understand the cancellation policy that if you ever need to cancel/change your session, please call us at least 24 hours in advance of your appointment time. Because your therapy time is held solely for you, there is a charge of 100% of the session fee for any cancellations less than 24 hours. SDCST reserves the right to change/modify the rates at any time, and we will let you know of any rate changes via written notice ahead of time. IT IS YOUR RESPONSIBILITY TO PROVIDE OUR OFFICE MANAGER WITH YOUR ENTIRE CREDIT CARD NUMBER OVER THE PHONE AS SOON AS POSSIBLE OR AT THE TIME OF SCHEDULING YOUR FIRST SESSION. PLEASE CONTACT OUR OFFICE MANAGER AT (858) 488-4810 TO PROVIDE HER WITH THIS INFORMATION IN ORDER TO SECURE YOUR APPOINTMENT TIME. Authorized Merchant: SDCST;12625 High Bluff Drive Suite #105, SD, CA 92130Name on Credit Card* First Last Last Four Digits of Credit Card Number.*Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date Electronic Signature*By typing your name here you are agreeing to the above terms. This field is equivalent to a hand-written signature.You must complete this form in its entirety even if you have made alternate payment arrangements with the office staff.PhoneThis field is for validation purposes and should be left unchanged. Save and Finish Later This iframe contains the logic required to handle AJAX powered Gravity Forms.