Myofunctional Therapy Information (Child) Myofunctional Therapy New Patient Information Form (CHILD birth through 17 years old) - New Step 1 of 8 - 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, Office Directions, Policies, & ProceduresInformation 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 Mission Beach. We also do virtual appointments. Carmel Valley Office Our Camel Valley office address is: 11622 El Camino Real Suite 100, San Diego, CA 92130 (***Located Inside Barrister Executive Suites, Office #1200***) . We are located in Suite 100, which is inside the Barrister Executive Suites, on the first floor. If it is your first visit with us, walk straight through the lobby to the Reception Area to check in. The person up front will direct you where to go, or the therapist will come to get you at the time of your appointment. After your first visit, for all following appointments, when you enter the lobby you may wait at the chairs under the directory sign, and the therapist will come out to greet you at the time of your appointment. ***NOTE: If you have an appointment after 6:00 pm, the front doors to the building will be locked, however please do not worry, as the therapist will meet you at the front door to the building at time of your appointment.*** Mission Beach (located inside Water and Sports Physical Therapy) Our address in Mission Beach is: 2999 Mission Blvd Unit 101 San Diego, CA 92109. Note: our office is located inside Water and Sports Physical Therapy. Water and Sports Physical Therapy is just past the Belmont Park parking lot, across the street. You will see the blue painted wall on the outside of the building. You can park next to the building (in the parking lot next to the blue painted wall), on the street, or in the large parking lot adjacent to the building. When you enter the office, please check in with the receptionist at the front and she will direct you where to go. Your therapist will come to get you at the start of your appointment time. Speech Therapy & Occupational Therapy Out-Of-Network Payment Details For speech therapy and occupational therapy, we are not an in-network provider, meaning that we do not accept or bill 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" insurance 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. Although we are not in-network with insurance for speech or occupational therapy services, many insurance companies will apply a portion of your payment to your out-of-network insurance deductible or will reimburse you according to your out-of-network benefits. NOTE: if you are seeking myofunctional therapy with our speech therapists, your insurance will view the sessions as out-of-network "speech therapy" (they do not recognize the service of myofunctional therapy, but on our Superbill it will appear as "speech therapy" codes). You may also potentially apply these charges towards your FSA. Please contact your insurance company for details. We are not responsible for working with insurance companies or for any insurance reimbursements to 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. This next section describes in detail our payment and insurance policy for speech and occupational therapy sessions. Please sign the section at the bottom showing you understand the policy. San Diego Center For Speech Therapy Payment and Insurance/Superbill Detailed Description NOTE: If you are seeking Myofunctional Therapy services and you have insurance, please see the section below titled FOR MYOFUNCTIONAL THERAPY PATIENTS INTERESTED IN ACCESSING MYOFUNCTIONAL THERAPY TREATMENT IN-NEWORK WITH THEIR INSURANCE. San Diego Center for Speech Therapy (SDCST) does not accept insurance for payment of services. You will be considered a self-pay patient. However, some of the services you receive may be covered under your insurance plan (e.g., “out of network” speech therapy) and you could submit information to your health plan for recoupment of some of the portion you will pay SDCST out of pocket. If you have commercial or Federally funded health coverage, recouping monies from your health plan will work in the following way: You will pay SDCST out-of-pocket for treatment SDCST will provide you with a superbill that lists procedure codes and diagnosis codes for your sessions.* The superbill provided to you can be sent into your health plan for the insurance allowable recoupment. Any monies received back from insurance belong to you. * NOTE: Not all portions of your session have a “procedure code” associated with them. This would mean that portions may be considered “non-coverable” by your insurance and may not be able to be recouped so there will not be a selection on the superbill for these portions. Possible non-covered services by some insurance companies may include but not limited to, myofunctional therapy, experimental or investigative techniques, services without objective measurements, services for maintenance. We are able to use speech therapy codes for myofunctional therapy assessments and treatments, but some insurances may not cover a full amount of such services. You have put your trust in SDCST to bring about the best successes for you or your child. You will want SDCST to utilize the best treatments for you or your child, and not just those covered by insurance. SDCST has opted not to take insurance because of the unfair restrictive nature of insurance and what would be allowed with insurance is not what is the best treatment. Tricare Additional Agreement for Tricare beneficiaries: SDCST does follow the Champus Maximum Allowable Fee Schedule regulations and the prices collected from you at the start of treatment have already taken into consideration the maximum allowable you can be charged on “covered services”. As mentioned in the (*) segment above, not all portions you pay out of pocket are “allowed” by your insurance however we will want to utilize these services in you or your child’s sessions. This document states that SDCST will treat your child with all services necessary even though they are not all reimbursable by Tricare. Myofunctional Therapy Payment Details We may accept your insurance for myofunctional therapy treatment sessions! This next section describes in detail our payment and insurance policy for myofunctional therapy sessions. Our Myofunctional Therapy assessments are always done by our Speech-Language Pathologists and are considered "out-of-network speech therapy" services (self-pay). After the assessment, some patients are eligible for the Myofunctional Therapy treatment sessions to be done by the Doctors of Physical Therapy that we work with who are also Myofunctional Therapists. These Physical Therapists are in network with nearly all PPO/POS insurances and can bill your insurance directly if you are eligible. Otherwise, you can continue to receive the Myofunctional Therapy with our Speech-Language Pathologists who are not in network with insurances (self-pay, and they can continue to provide you with the out-of -network speech therapy insurance superbill if you would like). FOR MYOFUNCTIONAL THERAPY PATIENTS INTERESTED IN ACCESSING MYOFUNCTIONAL THERAPY TREATMENT COVERED BY THEIR INSURANCE: If you have an insurance that our affiliated physical therapy company Water and Sports Physical Therapy, Inc. (Mission Beach/Poway) accepts, you may be able to access our myofunctional therapy treatment services utilizing your in-network insurance benefits. This does not apply to most HMO patients. Please speak with our office manager to determine which insurances our Myofunctional Therapist/Doctor of Physical Therapy at Water and Sports Physical Therapy (Mission Beach/Poway offices) accepts. If you intend to receive your myofunctional therapy treatment services utilizing your in-network insurance benefits through our affiliated physical therapy company, please note that your initial assessment will be done by our speech therapy company, which is not in network with any insurances. The initial assessment is self-pay, however we can provide you with an insurance superbill to seek reimbursement for this assessment as to your out-of-network speech therapy benefits. See the section above: San Diego Center For Speech Therapy Payment and Insurance/Superbill Detailed Description. After your initial assessment by our Speech-Language Pathologist and Certified Orofacial Myologist from our speech therapy company, if you have insurance that Water and Sports Physical Therapy accepts and there is medical necessity for physical therapy, you can have your PT/myofunctional therapy treatment sessions at the Mission Beach or Poway offices with our Doctor of Physical Therapy, as per your insurance benefits for PT. Sometimes they are able to do virtual/telemedicine appointments as well. For patients under the age of 5, the ability to receive Myofunctional Therapy by the Physical Therapists will be determined on a case-by-case basis. If at any point your insurance does not cover your treatment, you can continue your myofunctional therapy with the physical therapist or one of our other Myofunctional Therapists as a self-pay patient and we can provide you with insurance superbills accessing our services as “out of network” providers. NOTE: As a self-pay (non-insurance patient), you are responsible for paying our office directly 100% of the session cost, and we are not responsible for any amount your insurance does not cover if you were to submit a superbill. Please note that we only have the ability to treat you as an in-network insurance patient (directly billing your insurance according to the above listed description) if you are seen by our Doctor of Physical Therapy/Myofunctional Therapist, and it has been determined that your insurance will cover the services. We will need a referral with medical diagnosis codes from an MD, DO, chiropractor, dentist, or orthodontist within the first 45 days or 12 visits (whichever comes first) of the PT treatment. If you have Medicare, this is required before the first PT visit. NOTE: Our Speech-Language Pathologists who are Certified Orofacial Myologists are not in-network with insurances, and you would be a self-pay patient given insurance superbills if treated by them at any time. Moreover, our PTs who are Myofunctional Therapists are able to treat you as a self-pay patient if they do not accept your insurance or if your insurance does not cover the services. It is extremely important for you to understand that if you are being treated for myofunctional therapy by the physical therapists, your myofunctional therapy treatment plan may continue beyond your insurance coverage, and if for some reason you no longer qualify for insurance coverage, we strongly encourage you to continue your treatment until the therapist determines it is not longer necessary, even though you may have to pay out-of-pocket. The completion of treatment is determined by your therapist and should not be determined by insurance coverage. In order to have success in myofunctional therapy, the sessions typically entail 8-10 visits of a “Learning Phase” where we teach you the exercises and correct functioning, and then you continue on a monthly basis until treatment goals have maintained and stabilized at an unconscious level (i.e., until carryover on a daily basis, day and night, outside of the therapy session is achieved). Terminating therapy early can result in the loss of achieved skills and failure in ultimately achieving therapy goals. It is a benefit that we may accept your insurance, but we hope you will commit to therapy regardless of your insurance status. Please sign the area at the bottom showing that you understand the policy of our Myofunctional Therapy services. Missed Visits/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. Our missed visit fee is as follows: The fee for a no-show or cancellation of an evaluation with less than 24 hour notice is $100.00. For therapy sessions, the 1st no show or late cancellation is $50.00; 2nd and subsequent no shows or cancellations will be charged the full rate of the session that day. We may need to remove you from our schedule if there are more than 3 missed visits due to a late cancellation or no show. We understand that life happens and will handle those instances on a case-by-case basis. The time slot that you have chosen is reserved solely for you. 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 thank you for your understanding of our cancellation policy. IF WE WORK WITH YOUR CHILD AT HIS/HER SCHOOL 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.Patient or Patient/Guardian Signature:*By typing your name here you are agreeing to the above terms. This field is equivalent to a hand-written signature.Date* 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?*40 weeks in utero is considered full term. Was your child born full term (or at how many weeks gestation)?*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 (skin prick test or blood test)?*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 If "other", please describe:Describe your child’s health. Does your child get sick often? List if any of the above are/were recurrent issues:* Save and Finish Later Sleep Breathing & AirwayAirway-Centered Disorder (ACD) Screening: Unrecognized ACD has been acknowledged as a significant contributor to many chronic health, developmental, and behavioral issues. Identifying children at risk can improve their health, performance, and quality of life by improving their airways. The following survey may help determine if someone displays signs and symptoms associated with ACD. One or more signs may be indicative of compromised airways and further evaluation is recommended. This screening is not intended to be a diagnosis of any condition. Are you seeking any therapy with us for sleep-related breathing issues (mouth breathing, snoring, upper airway resistance, sleep apnea, etc.)?*YesNoDo you have any concerns with your child's sleep?*YesNoList your concerns with your child's sleep:*Does your child snore at all?*YesNoIf 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 If "other", please describe: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 Does your child stop breathing when snoring?*YesNoIDKHow many hours of sleep on average does your child get each night?*What time does your child eat dinner?*Would you consider this a large meal?*YesNoDoes your child snack after dinner?*YesNoPediatric Sleep QuestionnaireWhile sleeping does your child…Snore more than half the time?*YesNoIdkAlways snore?*YesNoIdkSnore loudly?*YesNoIdkIf your child snores, would you rate the severity as:*MildModerateSevereMy child does not snoreHave “heavy” or loud breathing?*YesNoIdkHave trouble breathing or struggle to breathe?*YesNoIdkIf you have additional comments with regards to the above questions, please explain here:Have you ever…Seen your child stop breathing during the night? (i.e., pauses in breathing or gasping sounds)*YesNoIdkIf you have seen your child stop breathing/pause/gasp when sleeping, how frequent:*Throughout the nightFrequentlyOccasionallyDoes your child…Tend to breathe through the mouth during the day?*YesNoIdkHave a dry mouth on waking up in the morning?*YesNoIdkOccasionally wet the bed?*YesNoIdkWake up feeling un-refreshed in the morning?*YesNoIdkHave a problem with sleepiness during the day?*YesNoIdkHas a teacher or other supervisor commented that your child appears sleepy during the day?*YesNoIdkIs it hard to wake your child up in the morning?*YesNoIdkDoes your child wake up with headaches in the morning?*YesNoIdkDid your child stop growing at a normal rate at any time since birth?*YesNoIdkIs your child overweight?*YesNoIdkIf you have additional comments with regards to the above questions, please explain here:This child often…Does not seem to listen when spoken to directly*YesNoIdkHas difficulty organizing tasks*YesNoIdkIs easily distracted by extraneous stimuli*YesNoIdkFidgets with hands or feet or squirms in seat*YesNoIdkIs “on the go” or often acts as if “driven by a motor”*YesNoIdkInterrupts or intrudes on others (e.g. butts into conversations or games)*YesNoIdkIf you have additional comments with regards to the above questions, please explain here:***As per the Pediatric Sleep Questionnaire, if 8 or more answers to the above listed questions are “yes”, consider referring for a sleep evaluation.***SDCST Myofunctional Sleep-Disordered Breathing QuestionnaireSLEEP BEHAVIORS: Does your child…Sleep with his/her mouth open or lips parted?*YesNoIdkFrequently wake up with:*(check those that apply) A dry mouth Headaches Excessive sweating Heart burn Chest pain Leg cramps Nightmares Aching in jaws or TMJ pain Choking or gasping Drool on the pillow Bed wetting (loss of bladder control) A need to get up to use the bathroom when sleeping Nasal congestion/stuffy nose upon awakening (which was not present when the child went to bed) None of the above Does your child need to drink water when sleeping (wants a water bottle by bed) or when waking up?*YesNoIdkDoes your child have trouble falling asleep at the beginning of the night?*YesNoIdkIf "yes", how long does it typically take your child to fall asleep?Does your child have trouble staying asleep through the night (wakes during the night)?*YesNoIdkTypically how many awakenings?*Average time to fall back to sleep*Does your child have any of the following when sleeping?(check all that apply) Nightmares Night Terrors Sleep walking Sleep talking Kick, twitch legs, or have leg jerks while asleep Appear to be a restless sleeper, tosses and turns, bed is a mess, or even falls out of the bed Clench or grind teeth at night Exhibit noisy breathing, gasps for air, sighs, or shows any breathing difficulty Excessive sweating when asleep Sleeps with neck extended (head/chin pointed upwards) Sleeps in a kneeling position with the butt in the air None of the above For any of the above listed behaviors, please describe how often you observe these:If you have additional comments with regards to the above questions, please explain here:DAYTIME BEHAVIORS:Does your child…*(check all that apply) Have difficulty waking to start their day (i.e., Do you have a hard time waking your child?) Often seem moody or irritable during the day Have difficulty maintaining concentration during the day Have hyperactive behaviors during the day (has difficulty sitting still) Have a diagnosis of ADHD If NO to the question above, do you suspect ADHD or are you concerned with ADD/ADHD? Have a problem being sleepy during the day (e.g., may fall asleep in the car or while watching TV) Have a learning disability, developmental delay, or poor ability in school Exhibit signs of depression Exhibit anxiety Have emotional problems Have sensory processing issues/disorder/concerns None of the above Does your child fall asleep during the day or take naps?*YesNoIdkHow often and typically how long is each nap?*Have a sucking habit or oral habit*YesNoIdkHave a history of a sucking habit or oral habit*YesNoIdkCheck each sucking or oral habit* Sucks Thumbs Fingers Lips Tongue Cheeks Objects Chews/Bites nails Chews or sucks on clothing Chews hair Other If "other", please describe:If you have additional comments with regards to the above questions, please explain here:Airway Health & Medical: Does your child...Does your child have any of the following?:(check all that apply) Frequent colds Frequent sore throats Frequent tonsillitis Excessive mucous Excessive congestion Allergies Difficulty breathing through the nose Complain of headaches Reflux History of reflux Excessive burping Digestive issues Picky eating Does not eat a full meal but rather snacks throughout the day Prefers to eat mostly carbohydrates Avoids foods that need to be chewed (such as meats) None of the above Does your child take medication for reflux?*YesNoIdkDo you manage reflux in any other way?*Does your child have large tonsils or adenoids?*YesNoIdkHas you child had his/her tonsils and/or adenoids removed?*YesNoIdkIf "yes", what age and why?Does your child need orthodontics, is currently undergoing or has had orthodontics in the past (e.g., expander, headgear, braces, etc.)*YesNoIdkPlease describe the orthodontic treatment or plans for treatment:*Have a history of nursing or breastfeeding related challenges such as any of the following:*(check all that apply) Issues with latching Clicking sounds while nursing Issues with swallowing Milk escaping from the nose Nasal congestion Reflux Colic Weight gain issues Failure to thrive Frequent spitting up/projectile vomiting Difficulty staying awake while nursing Excessively long feeds Frequent nursing Pain in mother (nipple trauma, bleeding, mastitis) Low milk supply in mother There were no nursing-related difficulties Has your child ever been treated for a tongue or lip tie?*YesNoIdkPlease describeDoes your child currently have a tongue or lip tie that you are aware of?*YesNoIdkCurrently have chronic or recurrent nasal congestion?*YesNoIdkWas congestion an issue in the past?*YesNoIdkHas your child had any surgery in his/her nose, throat, or mouth?*YesNoIdkPlease explain*Sleepiness QuestionnaireSLEEPINESS QUESTIONNAIRE: Note: “you” refers to the child, if filled out by the parents:How often do you fall asleep or get drowsy during class periods?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you get sleepy or drowsy while doing your homework?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you feel a lack of alertness during the day?*AlwaysFrequentlySometimesSeldomNeverN/AHow often are you ever tired and grumpy during the day?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you have trouble getting out of bed in the morning?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you fall back to sleep after being awakened in the morning?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you need someone to awaken you in the morning?*AlwaysFrequentlySometimesSeldomNeverN/AHow often do you think that you need more sleep?*AlwaysFrequentlySometimesSeldomNeverN/A Save and Finish Later 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 any of the following reasons or do you notice your child has any of the following behaviors:*Check all that apply… Referred for: Myofunctional Therapy Referred to us by a dentist, orthodontist or other medical specialist for dental, orthodontic, or sleep-breathing issues Referred for a tongue thrust or may have a tongue thrust Sits with his/her mouth open Sleeps with his/her mouth open Sits with the tongue between the teeth Has jaw pain Snores or has sleep apnea or has sleep-related breathing issues Clenches/grinds teeth Has had braces or orthodontics that have not worked Has a lisp None of the above What 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.SALIVA SWALLOWING: When you swallow saliva, do your lips squeeze tight together?*NoYesSALIVA SWALLOWING: When you swallow saliva, does your tongue come forward?*NoYesSALIVA SWALLOWING: When you swallow saliva, do the sides of your tongue go between your back teeth?*NoYesSALIVA SWALLOWING: Do your teeth close when you swallow saliva?*NoYesEATING: When eating, do you chew on one side more than the other?*NoYesEATING: Do you chew with your lips open?*NoYesEATING: Does your tongue move forward or down when you chew?*NoYesEATING: Do the sides of your tongue push between the back teeth when you chew?*NoYesEATING: After chewing, does the tongue push forward, down, or sideways when you swallow?*NoYesEATING: Do you choke?*NoYesHow often do you choke?DRINKING: When drinking, does your tongue touch the rim of the glass, bottle, or can?*NoYesDRINKING: When drinking, does your tongue push forward, down, or sideways when you swallow?*NoYesDRINKING: When drinking, do you choke or cough after you swallow?*NoYesLIPS REST POSTURE: At rest, are your lips parted during the day and/or night when sleeping?*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 clench or grind his/her teeth during the day and/or night when sleeping?*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?*YesNoHow 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 If "other", please describe: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 (n other words: is your mouth open or lips parted when 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 send any copies of reports, assessments, IEPs, or any other pertinent information to San Diego Center For Speech Therapy: 12707 High Bluff Drive Suite #200, San Diego, CA 92130 OR you may fax the documents to: 858-746-4113 OR you may email the documents to us: Info@SanDiegoCenterForSpeechTherapy.com 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 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.Name on Credit Card* First Last Last Four Digits of Credit Card Number.*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.NameThis 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.