New Client Information Packet Complex/Autism- Sequential IMPORTANT: Please Verify You Have The Correct Forms Use these forms if: You are or represent a client with Significant Learning and/or Development, Behavioral, Sensory, PANDAS, PDD-NOS, Aspergers or Autism related problems You reside within the USA. If either of the above items do not apply to you, please use the form packet designated for your situation found at: http://www.homeopathyhouston.com/client-forms/ --------------------------------------------------------------------------------------------------------- Please fill out the following forms completely and return them to Homeopathy Center of Houston. Additionally, please forward: A clear, legible copy of your/your child's original vaccination record if available. We realize some adults may no longer retain a vaccination record. If that is the case, please try to recall any vaccines from adulthood, and we can make a rough approximation based upon your age of your likely childhood vaccination history. A photo of your child at/near birth, a current photo of your child and, if applicable, a childhood photo before and after regression if any was observed. You may return materials via fax or mail. Please do not email forms. Email is not secure and not HIPAA compliant. Any information, including personal, medical, or financia information such as credit cards sent via email is at your own risk. Mailing address: Homeopathy Center of Houston Attention: Schedule Desk 7670 Woodway Drive, Suite 340 Houston, Texas 77063 USA If you need further assistance please call us at 713-366-8700 Fax: 713-366-8710
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New Client Information Packet Complex/Autism- Sequential
IMPORTANT: Please Verify You Have The Correct Forms
Use these forms if:
You are or represent a client with Significant Learning and/or Development,Behavioral, Sensory, PANDAS, PDD-NOS, Aspergers or Autism related problems
You reside within the USA.
If either of the above items do not apply to you, please use the form packet designated for your situation found at: http://www.homeopathyhouston.com/client-forms/
Please fill out the following forms completely and return them to Homeopathy Center of Houston.
Additionally, please forward:
A clear, legible copy of your/your child's original vaccination record if available. Werealize some adults may no longer retain a vaccination record. If that is the case, pleasetry to recall any vaccines from adulthood, and we can make a rough approximationbased upon your age of your likely childhood vaccination history.
A photo of your child at/near birth, a current photo of your child and, if applicable, achildhood photo before and after regression if any was observed.
You may return materials via fax or mail. Please do not email forms. Email is not secure and not HIPAA compliant. Any information, including personal, medical, or financia information such as credit cards sent via email is at your own risk.
Mailing address: Homeopathy Center of Houston Attention: Schedule Desk 7670 Woodway Drive, Suite 340 Houston, Texas 77063 USA
If you need further assistance please call us at 713-366-8700
Fax: 713-366-8710
Client Contact Information Today’s Date:________________
Referred by: _________________________________________________________________
How did you hear about us? [ ] Internet Search [ ] Age of Autism [ ] Conference _____________ [ ] Another client [ ] Other (please specify):____________________________________________
Phone: _________________________Other number: ____________________ I understand that consultations and products are provided on a fee for service basis, that is, all fees and costs are due and payable at the time service or products are rendered and I accept responsibility for their payment by check, cash, VISA or MasterCard. I understand there will be a $30 fee for checks returned for any reason. Ialso understand any charges unpaid by 20 days after a consult will incur a $10 late fee PER INVOICE DUE. For minor clients, both parents must sign below:
Homeopathy Center of Houston Disclosure and Consent for Services
I, ________________________________________________, understand that homeopathy is a complementary form of healing, and is not represented by Homeopathy Center of Houston, a subsidiary of Houston Center of Homeopathy, Inc. (“the Center”) as a replacement for standard medical care. This form of treatment is not intended to supplant or replace treatment given by a physician, physical therapist, psychotherapist, or other licensed practitioner. I understand that the Center’s homeopaths and other practitioners are not licensed medical doctors, nor do they represent themselves as such. The Center is providing educational services consisting of, but not limited to professional consultations for self-care and products to be self-administered. I understand that homeopathic remedies, personal care and over-the-counter self-care products may be provided by the Center for my convenience for extra charges, in addition to the cost of the professional consultations.
I understand that, due to the nature of disease, individual motivation for compliance with the consultants’ recommendations, and because people are biologically and genetically unique, that no claims or guarantees are or can be made as to the outcome of this advice. No cure, improvement or outcome is or can be guaranteed for any condition. Compliance with any suggestions or recommendations are undertaken by, and the responsibility of myself as client or parent/guardian of the client.
I acknowledge that I/my child is undertaking therapies without coercion which may evoke certain previously experienced and occasionally uncomfortable emotions and/or physical sensations, as part of the healing process. I realize that I should be willing to make a commitment to myself or my child to continue this therapy over whatever course of time it may take to complete my/his/her life timeline (usually 2-3 years), and to keep in communication with my practitioner if problems, concerns or discomfort should arise.
I accept all responsibility for compliance or non-compliance with the recommendations of the practitioners of the Center, at my discretion and agree to hold harmless the Center, its employees, practitioners, heirs, assigns or representatives for any unforeseen effects of these therapies. I also understand that homeopathy is incapable of creating any new pathology, it can merely elicit a “detoxification” or healing response if harmful elements have already been in the system, as a means of eliminating their long or short-term ill effects. I understand that homeopathic remedies are FDA-regulated, non-toxic, non-pharmaceutical, natural medicines.
In the event of dispute over services or products rendered by the Center, I understand that by signing this form, I acknowledge that I will attempt solution of the dispute first by means of communication with the practitioner, and second via arbitration/mediation, and waive my right to litigation.
I understand that it is strongly recommended that any prescribed medications from a medical doctor not be discontinued or changed while undertaking homeopathic care without first consulting both the prescribing physician and the practitioners of the Center. (The Center, however, does request that you keep your practitioner informed of any medications or therapies currently or previously undertaken, or that you plan to use, including herbal or nutritional supplements or drugs.)
I understand and accept the above terms and hereby request that the Center provide me with the services and products as outlined generally above, and specific to my/my child’s case. I understand that in the event of same day cancellations or no-shows, or if I cannot be reached at my appointment time, I will be billed the full amount of the scheduled consultation fee. I agree to provide payment at the time of service or provision of products by check, cash, VISA or MasterCard. (Fees subject to change.)
___________________________________________ ___________________ Client signature (or parent/legal guardian if a minor) Date
___________________________________________ ___________________ Client signature (2nd parent/guardian if client is a minor) Date Please initial one statement:
__________I agree to the publication of my/my child’s case study in a professional journal, presentation, lecture or in other professional or educational settings or publications with the express understanding that my/my child’s name or other identifying information will not be published or presented. __________ I DO NOT wish my/my child’s case to be presented, published, or in any way disseminated for any purpose, educational, professional or otherwise.
Credit Card Authorization to: Homeopathy Center of Houston
7670 Woodway, Ste. 340 Houston, Texas 77063
713-366-8700
Please complete the following information and fax or mail this form to our office. This information will be kept confidential and used only when charges are incurred for, but not limited to, consultations by telephone, page returns, remedies or other products, missed appointment or insufficient notice of cancellation fees, shipping and handling.
I hereby authorize Homeopathy Center of Houston to charge my credit card for services rendered, missed appointment or insufficient notice of cancellation fees and/or products provided by the Center in the course of homeopathic consultations. I understand that these charges will be made on the date of service, and I promise to pay all charges in accordance with my credit card company agreement. I understand that fees are due and payable at the time of service, and there are NO REFUNDS for services or products provided by the Center. We can no longer accept flex credit cards. If you have a flex plan, please file your invoices with your employer or insurance company. We apologize for any inconvenience. INTERNATIONAL CLIENTS – ONLY USE THIS FORM FOR CREDIT CARDS DRAWN ON USA BANK.
Check one: [ ] MasterCard [ ] Visa Account number:________________________
Expiration Date (mm/yy)__________________________
Name (as it appears on card):_______________________________________
Autism Treatment Evaluation Checklist (TEC) Bernard Rimland, Ph.D and Stephen M. Edleson, Ph.D.,
Autism Research Institute
Name of Child: ______________________________________________________________________M_____F_____ Age____________ DOB________________________________________
Form completed by: ____________________________________________________ Relationship_________________________________Today’s Date________________________
Please check the appropriate letter to indicate how true each phrase is: Part 1. Speech/Language/Communication: [N] Not true [S] Somewhat true [V] Very true N____S____V____1. Knows own name N____S____V____2. Responds to “no” or “stop” N____S____V____3. Can follow some commands N____S____V____4. Can use one word at a time
(No!, Eat, Water, etc.) N____S____V____5. Can use 2 words at a time
(Don’t want, Go home, etc.) N____S____V____6. Can use 3 words at a time
(Want more milk, etc.) N____S____V____7. Knows 10 or more words N____S____V____8. Can use sentences with 4 or more words
N____S____V____9. Explains what s/he wants N____S____V____10. Asks meaningful questions N____S____V____11. Speech tends to be meaningful/relevant N____S____V____12. Often uses several successive sentences N____S____V____13. Carries on fairly good conversation N____S____V____14. Has normal ability to communicate for his/her age
Part 2. Sociability: [N] Not Descriptive [S] Somewhat Descriptive [V] Very Descriptive N____S____V____1. Seems to be in a shell – You cannot reach him/her N____S____V____2. Ignores other people N____S____V____3. Pays little or no attention When addressed N____S____V____4. Uncooperative and resistant N____S____V____5. No eye contact N____S____V____6. Prefers to be left alone N____S____V____7. Shows no affection N____S____V____8. Fails to greet parents N____S____V____9. Avoids contact with others
N____S____V____10. Does not imitate N____S____V____11. Dislikes being held/cuddled N____S____V____12. Does not share or show N____S____V____13. Does not wave “bye bye” N____S____V____14. Disagreeable/not compliant N____S____V____15. Temper tantrums N____S____V____16. Lacks friends/companions N____S____V____17. Rarely smiles N____S____V____18. Insensitive to other’s feelings N____S____V____19. Indifferent to being liked N____S____V____20. Indifferent if parent(s) leave
Part 3: Sensory/Cognitive Awareness: [N] Not descriptive [S]Somewhat descriptive [V]Very Descriptive N____S____V____1. Responds to own name N____S____V____2. Responds to praise N____S____V____3. Looks at people and animals N____S____V____4. Looks at pictures and TV N____S____V____5. Does drawing, coloring, art N____S____V____6. Plays with toys appropriately N____S____V____7. Appropriate facial expression
N____S____V____8. Understands stories on TV N____S____V____9. Understands explanations N____S____V____10. Aware of environment N____S____V____11. Aware of danger N____S____V____12. Shows imagination N____S____V____13. Initiates activities N____S____V____14. Dresses self
ATEC p. 2 Part 4: Health/Physical/Behavior: [N] Not a problem [MI] Minor Problem [MO]Moderate problem [S]Serious problem N____MI____MO____S____1. Bedwetting N____MI____MO____S____2. Wets pants/diapers N____MI____MO____S____3. Soils pants/diapers N____MI____MO____S____4. Diarrhea N____MI____MO____S____5. Constipation N____MI____MO____S____6. Sleep problems N____MI____MO____S____7. Eats too much/too little N____MI____MO____S____8. Extremely limited diet N____MI____MO____S____9. Hyperactive N____MI____MO____S____10. Lethargic N____MI____MO____S____11. Hits or injures self N____MI____MO____S____12. Hits or injures others N____MI____MO____S____13. Destructive N____MI____MO____S____14. Sound-sensitive
N____MI____MO____S____15. Anxious/fearful N____MI____MO____S____16. Unhappy/crying N____MI____MO____S____17. Seizures N____MI____MO____S____18. Obsessive speech (repeats same words/speeches) N____MI____MO____S____19. Rigid routines N____MI____MO____S____20. Shouts, screams or shrieks N____MI____MO____S____21. Demands sameness N____MI____MO____S____22. Often agitated N____MI____MO____S____23. Not sensitive to pain N____MI____MO____S____24. “Hooked” or fixated on certain objects/topics N____MI____MO____S____25. Repetitive movements (Stimming, rocking, etc.)
