R.O.S.E. Communication & Therapy Services
Client intake / registration
J'Vohnne Rosario, M.S. · 773-457-1204 · rosecommunicationandtherapy@gmail.com
Demographics, contact, physician, school, diagnoses, and communication concerns.
Client registration
This is the practice registration. Bring what you have. Missing papers should never keep you from showing up.
Client legal name
Preferred name
Date of birth
Age
Pronouns
Sex assigned at birth (if useful for records)
Gender identity (optional)
Contact information
Street address
City
State
ZIP
Primary phone
Alternate phone
Preferred contact
- Call
- Text
Parent / caregiver
Caregiver 1 name
Relationship
Phone
Caregiver 2 name
Relationship
Phone
Emergency information
Emergency contact name
Relationship
Phone
Second emergency contact
Relationship
Phone
People authorized to pick up a child (if applicable)
Physician and diagnoses
Primary physician
Physician phone
Practice / clinic name
Diagnoses (as named by a physician or school team)
Medical concerns, hospitalizations, or precautions
Medications
Allergies / alerts
School / daycare
School, daycare, or program
Grade / classroom
Teacher or case manager
School phone
Current school or EI papers (if any)
- IEP
- IFSP
- 504 plan
- Early intervention
- None yet
- Not sure
Communication concerns
How this person communicates now
- Verbal speech
- Gestures
- Signs
- AAC system already in use
- Pictures
- Writing
- Other
If an AAC system is already in use, name it
Languages spoken at home
What communication concerns bring you here?
What would a good next step look like?
Prior therapy (history only)
R.O.S.E. currently offers speech-language therapy. Other disciplines listed here are history, not a promise that those services are offered in this practice.
Previous therapy services
- Speech-language
- Occupational therapy
- Physical therapy
- Developmental therapy
- None
Previous providers or programs
Who referred you, if anyone?
How fees will be named
Therapy session rates are named before evaluation or therapy begins—not published as a menu. Brief consultation is $25 per 15 minutes (private pay, not insurance). Late cancel and no-show fees are $25 unless waived. Educational and IEP consultation is separately billable.
I understand
- Therapy fees will be named before evaluation or therapy begins
- Brief consultation is $25 per 15 minutes and is not billable to health insurance
- This form is not a quote and not a weekly package I have not agreed to