Seeing Private Clients on the Side

CLIENT INTAKE FORM

Client name:
Date of birth:
Parent/guardian (if applicable):
Address:
Phone:
Email:
Emergency contact (name + phone):

REASON FOR SERVICES
What are you hoping to work on?
Who referred you (or how did you find me)?

HISTORY
Prior speech-language evaluation? (Y/N, date, where)
Current or past IEP / school services? (Y/N; please share a copy if available)
Relevant medical history (hearing, ENT, diagnoses, medications):
Other current therapies (OT, PT, ABA, counseling):

LOGISTICS
Preferred session day/time:
Session location (client home / other):
Anyone else who will be present during sessions:

SIGNATURES
Parent/guardian or client signature:
Date:

CONSENT FOR SERVICES AND PRIVACY NOTICE

1. SERVICES. I consent to speech-language services provided by
[Your Name], [credentials], license #[____] in the state of [____].
Services include assessment and treatment as described in the
treatment plan we review together.

2. PRIVATE PAY. I understand this is a private-pay practice. I am
responsible for the session fee of $[____] per [__]-minute session,
due at time of service. A superbill can be provided on request for
out-of-network insurance claims; reimbursement is not guaranteed.

3. CANCELLATIONS. I understand sessions cancelled with less than
[24] hours' notice, or missed without notice, are charged
$[____]. Illness and emergencies are handled with common sense.

4. RECORDS AND PRIVACY. Session records are kept confidential and
stored securely. Records are not shared with schools, physicians,
or other providers without written permission, except where the
law requires disclosure.

5. COMMUNICATION. I consent to scheduling contact by [text/email].

Client / guardian signature:                     Date:
Printed name:
Relationship to client:

CANCELLATION POLICY (one page, plain language)

My goal is a standing weekly time that works for your family.
That time is reserved for you.

1. If you need to cancel or move a session, please tell me at
   least 24 hours ahead. No fee, no problem.

2. Cancellations with less than 24 hours' notice, and missed
   sessions without notice, are charged $[____]. The first one
   is waived; life happens.

3. If [3] sessions in a row are missed, we will pause the
   standing time slot and restart scheduling when you are ready.

4. Illness: if anyone in the household is sick, stay home; we
   will reschedule or move that session to video with no fee.

Signature:                                       Date:

SUPERBILL CHECKLIST (what yours must include)

PROVIDER
[ ] Your name and credentials (e.g., MS, CCC-SLP)
[ ] Individual NPI number (free at nppes.cms.hhs.gov)
[ ] EIN or SSN (get an EIN; it is free and keeps your SSN private)
[ ] Practice address and phone
[ ] State license number

CLIENT
[ ] Name, date of birth, address (exactly as on the policy)

EACH SESSION LINE
[ ] Date of service
[ ] CPT code (92507 is the standard individual treatment code
    through the end of 2026; new codes replace it on January 1,
    2027. 92523 for a speech + language evaluation. Current codes:
    vochella.com/tools/cpt-2027)
[ ] Place-of-service code (12 = client's home, 10 = telehealth
    in home, 11 = office)
[ ] ICD-10 diagnosis code paired to the CPT code
[ ] Your charge for that session

TOTALS
[ ] Total charged and total paid
[ ] Your signature

Hand it to the family; they submit it to their own insurer.
Full walkthrough for families: vochella.com/funding/superbill