149 Yadkin Valley Rd, Suite 203 | Advance, NC 27006 | ph: (336)486-2393

Additional Developmental History

Please choose "yes" or "no" to the questions below. If you select yes, another field will appear for you to provide additional information for the therapist.

CONSENT FOR RELEASE OF INFORMATION

hereby consent to the release of information to/from (selected below) the speech-language pathologists of Happy Speech, PLLC and its affiliates for the coordination of services for my child. Specifically, I consent the following person(s)/entity(ies) to consult with Happy Speech, PLLC., via all means of communication regarding my child's status and progression with speech-language therapy.

By signing below, I understand that this consent will remain effective for one year from the date of submission/signing, and I may withdraw my consent at any time with written notice.

Non-Compete Acknowledgement

Review, Acknowledge & Sign Below

Heather Gladd, M.S. CCC-SLP, is committed to helping you recognize potential speech and language delays/disorders and understand the process of decreasing the negative impact speech and language delays/disorders may have on your child’s communication through screenings, observations, evaluations, treatment, etc. You need to be aware of options available to your child in order to reach the goals of increasing your child’s communication skills and his/her individualized treatment plan. Services provided from this therapist are not the only option available for your child. Please read and sign this acknowledgement to indicate your understanding of other available option(s) and your choice below.

In the event that Heather Gladd (or other Happy Speech therapists who may be full/part-time employees and/or contracted employees of nearby public school or private schools) draws clients/cases from the surrounding area(s), which may include private and public schools, it is the utmost goal to preserve the best interests of the client or the persons being served for speech and language/communication concerns, delays, and/or disorders. Heather Gladd (and other Happy Speech therapists) does not want to compete with additional current employers and will not accept Medicaid or bill private insurance at this time as this can take away from the public schools. Heather Gladd wants potential clients to be aware that she/contracted therapists cannot serve in IEP meetings if their child is eligible for services through the schools and the therapist works for the same school/entity. Heather Gladd wants potential clients to be aware that she cannot serve clients privately if they attend the same school site Heather Gladd/serving therapist works (i.e. a Happy Speech PLLC therapist cannot serve the same child privately and in the school as this would be a conflict of interest).

It is understood by the client that Heather Gladd will not involve herself in activities that conflict with the best interests of the clients (i.e. a therapist who works for the school system AND this company cannot attend an IEP meeting at the school of employment; a therapist that works at a particular school site may not be able to perform therapeutic services both publicly and privately due to potential conflict or violation of Principle of Ethics III, Rule B, which states that “Individuals shall avoid engaging in conflict of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.”) and possible professional settings in which the client or therapist may be involved (i.e. current employer from another company or government entity).

It is understood by the client Heather Gladd who may work for other companies or government entities will fully inform her administrator and potential/current clients by obtaining informed consent from the persons she serves (See Principle of Ethics I, Rule H which states that “Individuals shall obtain informed consent from the persons they serve about the nature and possible risks and effects of services provided, technology employed, and products dispensed…”). The client acknowledges that he/she must be aware of possible conflicts and be fully informed of other public/private therapy choices available (i.e. Therapy can be provided by the child’s school of residence and at the child’s school for free if the child is determined eligible for services by the IEP team at that school); however, if the client chooses to employ the services from therapists in a private setting, the client may incur costs (see payment agreement) that would not be required if provided services in the public schools.

Ultimately, it is the responsibility of the therapist to fully inform the company he/she works for and/or the public entity he/she works for and the client of potential conflicts. By signing below, you, the client, acknowledge that you have been fully informed of potential conflicts and you agree to pursue screening, testing, and/or therapeutic services from a private provider (i.e. Heather Gladd M.S. CCC-SLP), because you feel this therapist can best serve your child and his/her needs at this time. You are agreeing that you prefer this therapist’s screening, testing, and/or therapeutic services in the private sector over services that would typically be provided in the public sector. You have the right to determine whether and from whom you wish to receive professional services in the area of speech and language for your child’s communication delays and/or disorders.

Thank you for considering and/or choosing Heather Gladd as a private therapist for your child’s speech-language services.

The therapist, acknowledges she has fully disclosed she is an employee of Davie County Schools, has informed the client of the home school where services would be available for free, and has informed her employer of a potential private client who does not attend one of her school sites.

Happy Speech, PLLC

Today's Date:

Payment Policy Agreement

Please review and sign below.

Thank you for choosing Happy Speech, PLLC for your child’s speech-language services. We are committed to helping your child reach the goals of his/her individualized treatment plan. Our services, including travel and specialized therapy materials, depend on the timely payment of accounts. Please read and sign this policy to indicate your understanding and agreement.

Payment: Full payment is due at the time of service delivery, unless prior arrangements have been made and documented.

Insurance: Full payment is due directly to Happy Speech, PLLC. We do not currently accept or file insurance; however, we can provide a Super Bill with a description of the service(s) provided that you can use to file/negotiate with your insurance company. Your insurance policy is a contract between you and your insurance company. Please be aware that some, and perhaps all of the services provided by Happy Speech, PLLC may be non-covered services and not considered reasonable, customary and/or medically necessary under your current medical insurance plan. You may seek reimbursement for these services directly from your insurance company. If you are unsure about the process for filing a claim, we recommend that you call the customer service number on the back of your insurance ID card.

Speech-language services provided by Happy Speech, PLLC will be considered out-of-network by your insurance company. We are happy to provide you with all the information requested from the insurance company, including diagnoses codes and treatment plans--please indicate if your insurance company requires specific information. We are not responsible for any charges your insurance company considers to be in excess of reasonable or customary fees as well as those considered medically unnecessary.

By the execution hereof, the undersigned acknowledges his/her/their responsibility to pay any amounts not paid or reimbursed by insurance. The undersigned specifically accepts all financial responsibility for all services provided to the herein named patient by Happy Speech, PLLC and understands that regardless of what the insurance company agrees to pay, the undersigned will be responsible for the balance. Said balance will be paid without regard to the status of processing by the insurance carrier.

Usual and Customary Rates: Happy Speech, PLLC is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area and for our services. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Our current rates may be raised based on a variety of circumstances. If rates are raised prior to the client’s graduation from speech and language services and/or completion of evaluation services, the customer will be provided updated contracts 30 days before new prices go into effect.

Billing: Evaluation sessions are billed per evaluation. Therapy/observation/consultation sessions are billed per occurrence. If payment is not received per evaluation/session, services will cease until payment is received.

Cancellations: All canceled appointments will be rescheduled if possible. Missed appointments jeopardize the therapist’s travel time, planning, time, and report writing time, etc. Please be considerate of your therapist’s time by canceling appointments within a 24 hour period. See details below:

Canceled by you with no prior notice “no show”: session will be charged at 50% of the normal session rate.

● If the child is absent from school or other therapy location on the day of the scheduled therapy session, and you have not given prior notice of the absence directly to the therapist, the session will be charged at 50% of the normal session rate.

● Example: 30-minute sessions with no notice will be charged 50% of Happy Speech, PLLC therapy rate (i.e. $35 for a 30 minute session, $50 for a 45 minute session, etc. *this may change as rates increase with prior notice.)

Canceled by therapist: reschedule session at a time that the family/therapist is available. Late to sessions: If the therapist is late to a session, the time will be made up during the same day if time permits, or can be rescheduled at a time that meets the family/therapist’s needs at no additional charge. If the patient is late to an appointment, the session will end at the regular session time, and you will be responsible for the full session fee.

Other Billed Services: Happy Speech, PLLC offers additional services, including screenings, observations, evaluations, reports, attending conferences, additional speech/language samples, etc. These services will be billed in addition to the therapy session charges with prior notification/documentation.

Method of Payment: You will receive an invoice/Super Bill for the service(s) provided in the event you would like to request reimbursement through your insurance provider. Please let your therapist know if you need this documentation. We currently accept the following forms of payment:

*Cash--exact change
*Checks paid to the order of Happy Speech, PLLC. (*returned checks incur a $20 fee).

*Venmo @Heather-Gladd
*Debit/Credit Card additional fees/charges may apply.

Please indicate your understanding and agreement to the payment policy from Happy Speech, PLLC by signing below: