New Patient Intake Forms

Please complete the forms below prior to your first visit. Completing this online saves time at check-in and lets your therapist review your information before you arrive. If you have any trouble, call us at (201) 564-0641.

Patient Full Name

Therapy Agreement

We strive to provide each patient with the highest quality of care while attempting to accommodate your schedule for your convenience. Your consistent attendance of the planned treatment regimen is paramount to your recovery.

While we understand emergencies and unplanned conflicts occur from time to time, last minute cancellations or missing appointments without any notice to us hinders our ability to deliver exceptional care to all of our patients. Please work with us to minimize these occurrences so we can better serve you and our other patients by adhering to the following:

If you are unable to keep a scheduled appointment, we request that you notify us no less than 24 hours in advance so that your appointment can be rescheduled, and enable us to open that slot for someone else in need.
If you arrive more than 20 minutes late to your appointment, your appointment may need to be rescheduled if our availability doesn't allow for us to accommodate your full appointment time.
If you cancel or no-show 2 consecutive treatment sessions or have repeated non-consecutive cancellations, your appointment time may be filled with another patient.
All no-shows and cancellations will be documented in your medical record and appropriately reported to your physician, insurance carrier, and adjuster or case manager as applicable. Three (3) missed appointments constitutes non-compliance and may result in the discharge of your therapy program.

We believe that this agreement is necessary for the benefit of our patient care as a whole so that we may continue to provide quality services convenient for all. We appreciate the opportunity to be a part of your rehabilitation and wish you a speedy recovery. Thank you for your anticipated cooperation and consideration for our staff and other patients.

I have read, understand, and agree to the Therapy Agreement and Cancellation Policy above.

Statement of Financial Responsibility

Advance Rehabilitation Services, PA appreciates the confidence you have shown in choosing us to provide for your rehabilitative needs. The services you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure payment in full of your fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for the payment of your bill.

You are responsible for payment of any co-payment at the time of service and for any deductible/coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue therapy past your approved period, you will be responsible for your account balance in full. If your account is not paid in full and is referred to a collection agency, any fees incurred in collecting on your unpaid balance will be your responsibility. For your convenience, we accept cash, checks, Venmo, and most major credit cards (4% fee may apply). Payment is expected at the time you receive your bill. Payments can be made in person at the office, mailed to the address on your statement, or by calling the office at (201) 564-0641.

By checking below, I confirm I have read the above policy regarding my financial responsibility to Advance Rehabilitation Services, PA. I certify that the information provided is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Advance Rehabilitation Services, PA for the full and entire amount of all bills incurred, if applicable, for any amount due after payment has been made by my insurance carrier.

I have read and agree to the Statement of Financial Responsibility above.

You agree that in order for us to collect any amounts you may owe, we may contact you by any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and use of automatic dialing, as applicable.

I agree that Advance Rehabilitation Services may contact me by phone, text, or email as described above.

You will receive calls and/or text messages that deliver autodialed or pre-recorded telemarketing messages from an automatic telephone dialing system. Your consent to receive such calls and/or text messages is not a condition of any purchase of a service or product.

I have read this disclosure and agree that the Provider and/or their representatives may contact me as described above.

I acknowledge that the Notice of Privacy Practices and Notice for Federal Civil Rights is posted at the location in which I am receiving treatment, and that I have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided to me.

I acknowledge the Notice of Privacy Practices and Notice for Federal Civil Rights as described above.

Consent to Treatment and Authorization to Release Information

I am aware of my diagnosis and voluntarily consent to have Advance Rehabilitation Services, PA, through its appropriate personnel, provide evaluation and/or treatment as prescribed by my physician and/or recommended by my therapist. I understand the practice of Occupational, Physical, and Speech Therapy is not an exact science, and I acknowledge that no guarantees have been given to me regarding the successful completion or the results of the treatment provided. I understand that the treatment I receive is limited to Occupational, Physical, and/or Speech Therapy services and that I shall seek treatment from another medical professional for all other issues I may experience. I understand that I have the right to ask questions at any time during the course of my care, but I am ultimately responsible for my and/or the above-named patient's health/medical decisions.

I consent to treatment as described above.

I further authorize Advance Rehabilitation Services, PA to release to appropriate agencies any information acquired in the course of my or the above-named patient's examination and treatment necessary to secure payment for services provided.

I authorize the release of information necessary to secure payment, as described above.

Relationship to Patient (person signing above)

Self Parent/Guardian Other

If Other, please specify

Typed Signature (Full Legal Name)

Date

Patient Information

Last Name

First Name

Middle Initial

Date of Birth

Social Security Number

Marital Status

Sex

Male Female Non-Binary/Third Gender Prefer not to say

Preferred Pronouns (optional)

Address

City

State

Zip

Home Phone

Mobile Phone

Preferred Appointment Reminder Method

Text Call Email No reminder, please

Employer Information

Employer Name

Employer Phone

Employment Status

Employer Address

Employer City

Employer State

Employer Zip

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Relationship to Patient

If Other, please specify

Physician & Referral Information

Referring Physician Name

Referring Physician Phone

Script/Prescription Date

Services Ordered

PT – Physical Therapy OT – Occupational Therapy ST – Speech Therapy

Post-Surgical?

Yes No

Surgery Date, if applicable

Date of Injury / Onset

Body Part(s) Affected

Received Outpatient Therapy Before?

Yes No

How did you hear about us?

Primary Insurance Information

Insurance Company Name

Policy or Claim #

Group #

Insurance Company Phone

Policy Holder Name

Policy Holder Date of Birth

Patient's Relationship to Policy Holder

Self Spouse Dependent Other

Secondary Insurance Information (backup if Auto, Workers' Comp, or Litigation)

Insurance Company or Attorney Name

Policy or Claim #

Group #

Insurance/Attorney Phone

Policy Holder Name

Policy Holder Date of Birth

Patient's Relationship to Policy Holder

Self Spouse Dependent Other

Additional Questions

Is this Work-Related?

Yes No

Adjuster Name & Phone

Is this Auto-Related?

Yes No

If Auto-Related, State

Date of Accident

Medicare Only (if applicable)

Do you have Medicare?

Yes No

Currently receiving Home Health Services?

Yes No

If yes, agency name & type of service

Received home health services in the past 60 days?

Yes No

Currently residing in a Skilled Nursing Facility?

Yes No

If yes, name of facility

If in a Skilled Nursing Facility, are you on the “Medicare Unit”?

Yes No

To be completed by the patient. Please answer as completely as you can — this helps your therapist plan safe, effective care.

Why are you seeking therapy today?

Spoken Language(s)

Family Physician / Internist Name

Family Physician Phone

Preferred Language for Healthcare Information (Patient)

Preferred Language for Healthcare Information (Guardian/Healthcare Proxy, if applicable)

Any religious or cultural needs we should be aware of?

No Yes

If yes, please explain

Any special learning needs?

No Yes

If yes, please explain

Hearing Difficulty?

No Yes

Speaking/Communication Difficulty?

No Yes

Medical History

Please check all conditions that apply to you.

If you checked Fracture(s)/Total Joint Replacement, please list date(s) and area(s)

Family History of any of the following? (check all that apply)

In the past month, have you frequently felt down, depressed, or hopeless?

Yes No

In the past month, have you had little interest or pleasure in doing things?

Yes No

Other mental/emotional health concerns

In the past three months, have you experienced any of the following? (check all that apply)

Changes or difficulty with Bowel Changes or difficulty with Bladder Night Sweats Fever

Are you currently in pain?

Yes No

If yes, location of pain

Are you under the care of an MD for any of the above conditions?

Yes No

Allergies

Surgeries within the last 3 months (include dates)

What are your rehabilitation goals?

Fall Risk Assessment

Please check all that apply to you

I have fallen within the last year A fall resulted in an injury I am afraid of falling I have recently felt unsteady on my feet or in my wheelchair I have vision problems that are not corrected by glasses I use sedatives that affect my level of alertness during the day I have memory or cognitive difficulties I have a lower-extremity disability that affects my walking

If you have fallen, how many times in the last year?

Nutritional Screening

Please check all that apply to you

Unexplained weight loss (more than 5% in the last 30 days) Recent loss of appetite or aversion to food Difficulty swallowing Decrease in food intake (less than 50% for 3 or more days) Under the care of a doctor for a nutrition-related condition

Current Medications (list all medications, dosage, and frequency)

I am not currently taking any over-the-counter or prescribed medications/herbals

Correct, I am not taking any medications

Are all medications prescribed by a physician?

Yes No

This section is optional, but it helps your therapist prepare for your first visit.

Are you currently experiencing pain?

Yes No

If yes, please describe the location(s) of your pain or symptoms

Best level of pain in the last week (0 = none, 10 = worst imaginable)

Current level of pain

Worst level of pain in the last week

What makes your pain or symptoms worse?

What makes your pain or symptoms better?

Are your symptoms:

Getting worse The same Improving

How are you able to sleep at night?

Fine Moderate Difficulty Only with Medication

Do you have pain at night?

Yes No

When did your problem begin?

Have you been treated for this before?

Yes No

If yes, when and how?

Patient-Specific Functional Scale

List up to three (3) activities you have difficulty doing because of this condition. 0 = unable to perform, 10 = able to perform at your pre-injury level.

Activity 1

Rating for Activity 1

Activity 2

Rating for Activity 2

Activity 3

Rating for Activity 3

Intake Form Classic

New Patient Intake Forms

Therapy Agreement

Statement of Financial Responsibility

Consent to Treatment and Authorization to Release Information

Patient Information

Employer Information

Emergency Contact

Physician & Referral Information

Primary Insurance Information

Secondary Insurance Information (backup if Auto, Workers' Comp, or Litigation)

Additional Questions

Medicare Only (if applicable)

Medical History

Fall Risk Assessment

Nutritional Screening

Patient-Specific Functional Scale

Follow Us

Therapy Services

Advance Occupational Therapy Services