CONSENT TO TREATMENT
I consent to the following treatment as ordered by my physician and outlined in the treatment plan of care. I understand the risks and benefits of the treatment and I understand that I can ask questions to the treating clinician at any time regarding the treatment.
Clinical location —Please choose an option— Antelope Valley (Palmdale) Los Angeles San Gabriel Valley (West Covina) Bakersfield
Is your primary language spoken English? Yes No
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services? Yes No
If yes, please provide language needed
No, I would like to opt out of interpreter services Yes No
Please check the appropriate therapy service:
Speech Therapy: Speech therapy is an intervention service that focuses on improving a one's speech and ability to understand and express language, including nonverbal language. Services will include areas of articulation, stuttering, receptive and expressive language disorders, voice, social skills, auditory processing disorder, and Augmentative/Alternative Communication (AAC) Occupational Therapy: Occupational therapy can help improve their motor, cognitive, sensory processing, communication, and play skills. The goal is to enhance development, minimize the potential for developmental delay, and help families to meet the special needs of their infants and toddlers
The recommended treatment areas and service level will be outlined in the Assessment Report provided and explained to you by the clinician. Your permission is needed to implement the assessment recommendations and to further develop treatment plan goals and objects. I agree to the service plan that will be/has been created for the client. I understand that my consent is voluntary and that I may refuse these services at any time. I do not want to receive these services.
PHOTO RELEASE FORM
DV Therapy has my permission to use my photograph publicly to promote the office. I understand that the images may be used in websites, print publications, online publications, presentations, and/or social media. I also understand that no royalty fee or other compensation shall become payable to me by reason of I give consent I do not consent
VIDEO RELEASE FORM
DV Therapy has my permission to record my therapy sessions. The video recording will be used for training purposes. It will not be made public and will have internal use only. Once the video is no longer needed, it will be deleted. I give consent I do not consent
MAKE-UP SESSIONS
I will accept an alternative therapist when my therapist is absent. I agree with the above statements
Volunteers / Interns
DV Therapy Inc fosters a learning environment for volunteers and interns to receive observation hours, as well as provide treatment to clients with guidance and supervision by DV Therapy's treating therapists. I agree with the above statements
CANCELLATION POLICY
A great deal of effort goes into arranging your treatment schedule. It is important to realize that this therapy time is being held exclusively for you. Clients who make the best and most rapid progress are those who diligently follow the recommended treatment schedule.
If you must cancel an appointment FOR ANY REASON, the office must receive a 12-HOUR NOTICE by phone/text/email prior to the scheduled session or it will be considered a last minute cancellation. This policy enables us to keep our charges reasonable as well as retain our excellent speech-language therapists. If a session is cancelled last minute a charge of $30 will be due at the beginning of the next session.
As a courtesy, the Scheduling department sends out a confirmation text two days before the session – if the front office does not hear back that the session is confirmed, or prior alternative arrangements have been made, the office will assume that the session will proceed as scheduled. Please make a point of confirming with the office so there is no confusion regarding the scheduled session.
If you confirm the appointment and do not show, or come later than 15 minutes past the start time of the appointment, you will be subjected to the $30 last minute cancellation fee.
If there is an emergency, or you are sick, and you must cancel last minute (within 12 hours of session) you will be subjected to a $30 cancellation fee if proof of emergency or a doctor’s note is not provided.
Excessive cancellations - two or more last minute cancellations or cancellations that exceed 20% of approved authorization – the client will be at risk of being returned to the funding source or placed on a service hold. If a client is on a service hold, DV Therapy will not be able to hold/reserve the client’s time slot.
If you need to cancel the session, and you have given proper notice, the office will work with you to reschedule the appointment. A reschedule for a cancelled appointment should take place within 14 days of the original appointment.
If therapist is unavailable for the client session, DV Therapy will try to find an alternate therapist and/or find a date for a reschedule.
As a rule, therapy sessions will not be conducted on Federal holidays unless a special arrangement has been made between you and your therapist.
FINANCIAL RESPONSIBILITY AGREEMENT
This agreement must be signed and returned to our office prior to the commencement of treatment.
Client Name (required)
Client Birthdate (required)
Email (required)
I acknowledge receipt of the DV Therapy Client Service Agreement, and agree that I will be responsible for the payment of charges incurred as outlined in the packet. Specifically, I agree to pay for every scheduled appointment, whether I attend, cancel or miss the appointment, if I do not adhere to the guidelines for cancellation. Further, if any collection activities are necessary, I agree to pay all the expenses of such activities, including reasonable attorney’s fees and court costs.
Client Contact
Primary care physician
I have a primary care physician Yes No
[group group-physician] Physician’s Name
Physician’s Phone number
Physician’s Address
Physician Email
I give permission for DV Therapy to discuss and release information to the primary care physician. (required) Yes No
Patient's Date of Birth (required)
Signature: Type out name as your signature (required)
Accept Terms (required): Click here for our terms
Optional: If you would like to provide any documents such as diagnostic evaluations, IEP's and/or other evaluations, please upload here.
CLIENT/FAMILY RIGHTS AND RESPONSIBILITIES
You have the RIGHT to:
Effective behavioral treatment
Be treated with dignity and respect
Receive service that is considerate and respectful of your spiritual needs, beliefs and values
Receive services in a safe setting, free of all forms of abuse or harassment
Receive services without discrimination of age, ability, gender, race, spiritual beliefs, ethnic origin, marital status, sexual orientation, or financial status
Receive as much information needed about treatments in order to provide informed consent or refuse treatment
Access information on the progress of treatments
Know the benefits and potential limitations of proposed treatments
Refuse to participate in clinical research
Access your records within a reasonable timeframe, except specified by law
Express concerns or complaints about services without fear that the quality of your services will be affected
File a grievance with DV Therapy Inc. by calling (323) 426-6402 or by writing:Client Relations
File a grievance with the Secretary of the Department of Health and Human Services:[email protected]
You have the RESPONSIBILITY to:
Refrain from demands for inappropriate or treatments that are not evidence-based
Keep appointments and minimize cancellations
Respect the rights, property, and privacy of other DV Therapy, Inc. clients and staff
Report accurate and complete information regarding all matters relevant to treatment
Be informed and ask questions regarding your treatment
Follow the directions of the clinicians regarding treatment
Promptly pay your bills
Be an active participant in therapeutic treatment
Conduct yourself in a respectful manner
Remember: Being a good consumer does not mean being a silent partner!ASK questions when you have themSPEAK UP when you have concernsEXPRESS YOUR APPRECIATION when you are satisfied with your treatment
Client History
