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Meghan Murphy and Associates_ LLC

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Meghan Murphy and Associates_ LLC Powered By Docstoc
					Meghan Murphy and Associates, LLC                Erin Anderson and Associates, PC
Speech and Language Therapy                             Occupational Therapy
2151 W. Roscoe 1W                                       2151 W. Roscoe 1W
Chicago, IL 60618                                       Chicago, IL 60618
meghanmurphyandassociates@gmail.com                     erin@erinandersonassociates.com

                               F.R.I.E.N.D.S. Groups!
                         Fun Regulation Interaction Engagement
                           Nonverbal Developmental
                                    Social skills

GENERAL INFORMATION, APPLICATION & FEES
Thank you for your interest in the FRIENDS groups. Enabling children to form successful social
interactions through play is the goal of this program. Some of the themes we will cover include: the
“engine program” to promote self-regulation, processing emotions, initiating play with others, strategies
for regulation at school/home, and reading nonverbal cues. What makes this program unique is that each
therapist will support the growth of relationships while fostering social-emotional development, sensory
processing, self-esteem and communication. Functional development levels of each child will help
determine the placement and size of the group that will best facilitate peer interactions, learning and
enjoyment.

CHILD’S NAME:_______________________________________________________________
CHILD’S DATE OF BIRTH: _______/________/_______ CHILD’S AGE: ________________
SCHOOL: ___________________________________________ GRADE: ___________

FAMILY INFORMATION (Must be completed for all families)
Home Address:
______________________________________________________________________________
City, State, Zip:
______________________________________________________________________________
Family Email:
______________________________________________________________________________
Father: ____________________________________
Home #: ___________________ Work #: _____________________
Cell #: ___________________
Mother: ____________________________________
Home #: ___________________ Work #: _____________________
Cell #: ___________________
Emergency Contact (other than parent): ____________________________________
Home #: ___________________ Work #: _____________________
Cell #: ___________________ Pager #: _____________________

PLEASE CHECK SERVICES YOUR CHILD CURRENTLY RECEIVES
___SPEECH-LANGUAGE THERAPY PROVIDER __________________ PHONE ______________
____ OCCUPATIONAL THERAPY   PROVIDER __________________ PHONE_______________
____DEVELOPMENTAL THERAPY PROVIDER __________________ PHONE_______________
____ SOCIAL WORK            PROVIDER __________________ PHONE ______________
____ PHYSICAL THERAPY       PROVIDER _________________ PHONE ______________
____OTHER                   PROVDIER __________________ PHONE ______________
                                                                                                          2

PLEASE INITIAL EACH STATEMENT BELOW TO INDICATE YOUR AGREEMENT
________ I will inform the professional staff if there are any medical issues that might interfere with my
child’s participation.
_________ From time to time videotaping and or photography may be done to support the therapist’s
intervention process. Videotaping will be used for 3 purposes: 1- as an educational tool for staff training
of Meghan Murphy and Associates, LLC and Erin Anderson and Associates, PC. 2-Video clips shared
with parents (of group members only) to maximize communication with parents and illustrate progress,
new vocabulary and skills being learned. 3-as a tool within the group setting to illustrate skills/behaviors
to participants.
_________I agree that I will keep all videos and email summaries regarding my child and other children’s
participation in the FRIENDS group completely confidential.
 ________ If appropriate, I give permission to Meghan Murphy and Associates, LLC, and Erin Anderson
and Associates, PC to contact my children’s current therapists, in order to discuss goals and treatment
planning, and to provide the most comprehensive experience possible.


FRIENDS REGISTRATION POLICIES
    Consistency, as with all therapies, is a necessary component to the FRIENDS program in
     order to insure its success and your child’s success.
    Cancellations are strongly discouraged and should be considered only as a result of sickness or in
     an emergency situation. All other conflicts such as birthday parties, sports or family activities
     need to be discussed at the time of scheduling so that the program maintains its weekly
     consistency.
    Please do not bring your child to group if they have been ill within the previous 24 hours.
    Since the group’s purpose is to create an interactive environment between children, cancellations
     directly involve the entire group’s participation on that specific day. Due to the nature of the
     program, there will be no refunds or credits issued for missed sessions. Group rates have built in
     cancellations as most children do get sick at some point in the school year. As a result the cost is
     lower compared to paying on a weekly basis.
    Please do not bring any unapproved snacks to groups due to severe allergies of some of the
     participants.
    Specific concerns about your child and their goals are important to us and are addressed at the
     parent conferences. If an emergent concern arises, please leave a voicemail for your therapist
     prior to group. Follow up will be done at the parent conference.

    INSURANCE BILIING: PLEASE READ CAREFULLY***
        Meghan Murphy and Associates and Erin Anderson and Associates do NOT submit to your
         insurance company for reimbursement. However, invoices will be emailed on a monthly
         basis that are coded are accepted by insurance companies.
        We strongly recommend that you check with your insurance company for benefits and
         reimbursement rates as each policy varies.
        Weekly, individual notes are not provided as this is a group setting. If a letter of medical
         necessity is required you may obtain one from your pediatrician, or from us at a small,
         additional cost.

SCHEDULING
   FRIENDS groups will meet once a week for 2 hour session.

       Groups will begin the week of June 13th and run through August 12th 2011.
                                                                                                           3


       There will be no groups the week of July 4-9 Spring Break.

PAYMENT SCHEDULE
   Please note that applications are processed on a first-come, first-serve basis. A timely application
    and payment will reserve your child’s placement in the Summer 2011 FRIENDS Groups.
   Application and deposit of $300 is due for returning participants by April 15th. Spots are given on
    a first come basis. The fee for the summer FRIENDS Groups is broken down into 2 payments:
    $1400 total 7 sessions, 14 hours.
   $600 due the first week of camp June 13th.
   $500 due July 11th week of camp.
   Once you are registered you will be assigned a therapist to pay (Meghan or Erin).
   Statements will be coded and formatted for insurance purposes and given to each client.

WHAT IS INCLUDED IN THE COST OF GROUP?:
   Your child’s participation in FRIENDS group on a weekly basis for 2 hours.
   Weekly written summaries emailed to you describing each activity and its purpose, new
    vocabulary or concepts, as well as occasional homework assignments to be completed before
    the next session.
   A 20 minute conference at the end of the session with your child’s therapists to discuss goals
    and the individual progress of your child.

__________ (please initial) I understand that if I am interested in more feedback or information
regarding my child’s participation in group, I can schedule a time to talk my child’s therapist. This
will be billed at the regular hourly rate.

I give my permission for my child to participate in the summer 2011 FRIENDS Groups provided through
Meghan Murphy and Associates, LLC, and Erin Anderson and Associates, PC. I have read and
understand the registration and refund policies in the general information and fees. I understand that there
will be no refunds or credits issued for missed sessions and that any/all payments are nontransferable.

___________________________________________ _____________________
(PARENT’S SIGNATURE)                          (DATE)

FRIENDS GROUP PARENT QUESTIONAIRE

1. What are your goals for your child in regards to their participation in the FRIENDS group?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________



2. In a few words describe your child’s personality.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. In your opinion, what are some of your child’s strengths?
                                                                                                           4

_____________________________________________________________________________________
_______________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________

4. In your opinion, what are your child’s areas of challenges?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________
______________________________________________________________________________

5. How does your child interact with other children?
_____________________________________________________________________________________
_______________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________

During each group session, a healthy snack will be provided.
Any dietary restrictions / food allergies?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________

If so, please provider a Medical action plan from your doctor detailing steps to be taken in the event of an
allergic reaction.

APPLICATIONS WITHOUT PAYMENT WILL NOT BE CONSIDERED COMPLETE.

Applications can be mailed to:

Erin Anderson and Associates
2151 W. Roscoe 1W
Chicago, IL 60618

				
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