• Frangelica Leo 158-01 Crossbay Blvd. Howard Beach, NY 11414 347.593.TALK TheLanguageLoungeNY@gmail.com
  • Welcome to The Language Lounge!


    Thank you for choosing The Language Lounge to help meet your child’s communication and/or feeding needs. We realize there are many options from which to choose and we appreciate the opportunity to assist you with this important process.
    Please take time to fill out as much information as possible regarding your child’s developmental history as this information can be vital to the direction of the therapy plan. We understand that these forms can be time consuming; however it is important that we have as much information as possible prior to your first visit so that we may provide the best possible service for your child. If your child has any recent evaluations completed by other health professionals (psychologist, IEP, etc.). Please complete and submit. We look forward to meeting you and your child!
    Sincerely,
    Frangelica Leo, M.S., CCC-SLP, TSSLD
    Clinical Director of Related Services
    Speech-Language Pathologist

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  • Speech and Language Survey

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  • Pre-natal/Birth History


  •  Medical History

    Please check if your child has had any of the following (and if so, at what age):


  • Current General Health


  • DEVELOPMENTAL HISTORY

    Age when child: (If you cannot remember specific time, please indicate if it occurred at the expected time or if it was delayed)

  • Does your child:


  • LANGUAGE DEVELOPMENT

  • Age when your child:


  • SOCIAL DEVELOPMENT

  • How does your child handle...


  • SCHOOL HISTORY


  • CONTACT INFORMATION


    At times we may need to contact you for appointment reminders or other concerns. Please complete only the items below that you authorize as a method of contact. Note: Home address, one phone number and one e-mail address are required.

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  • Health Policy


    Help and cooperation is required in order to maintain a healthy environment. A child must be
    Temperature-free for 24 hours before returning to therapy. If your child has vomiting and/or
    diarrhea, he/she should not return to therapy until 24 hours have passed since the last episode of the same. Children will not be seen if any of the following is present:
     Too ill or uncomfortable to function in the therapy setting
     Continual runny nose
     Thick or discolored nasal discharge
     Excessive sneezing or coughing and mucus-producing cough
     An elevated temperature.
    Please contact your therapist and cancel session if the above applies to your child.

    Duty to Warn and Protect


    When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

    Public Safety

    Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.

    Abuse


    If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.

    Prenatal Exposure to Controlled Substances


    Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

    In the Event of a Client’s Death


    In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child or spouse’s records.

    Professional Misconduct


    Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

    Judicial or Administrative Proceedings

    Health care professionals are required to release records of clients when a court order has been placed. In the event of a court order, only the minimally acceptable amount of information will be revealed. Additionally, if a client files a complaint or lawsuit against anyone affiliated with The Language Lounge; relevant information regarding the client may be disclosed for the purpose of formulating an appropriate defense.

  • Photocopy Authorization
    I permit a photocopy of this consent form as if it were an original executed consent.

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  • By signing below, you are attesting to the accuracy of the above statements including all consents and authorizations implied therein. A copy of this agreement is available upon request.

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  • Should be Empty: