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DV Therapy | Adult Form
 

Adult Form

    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.



    YesNo


    YesNo


    YesNo

    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


    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


    I give consentI do not consent

    VIDEO RELEASE FORM


    I give consentI do not consent

    MAKE-UP SESSIONS


    I agree with the above statements

    Volunteers / Interns


    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.

    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.


    TextEmailPhone

    Emergency Contact


    YesNo

    [group group-emergency]

    [/group]

    Scheduling Make-ups


    SingleWidowedDivorcedMarried

    Speech, Language, Voice, Cognition, and Hearing History

    Medical History

    Provide the approximate ages at which you suffered the following illnesses and conditions and any relevant information:


    Primary care physician


    YesNo

    [group group-physician]


    [/group]


    YesNo

    5 star ratingI love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing just amazing. My little one is always excited to come and see her since day 1. Everyone here is amazing such great energy. I always see little ones come excited and leave excited!
    read more
    Bianca C. Avatar
    Bianca C.
    1 year ago
    My 2 year old son has been improving so much over the last few months & im very thankful for it ! Ms Natalie is so patient with him he loves going to see her !
    read more
    Stephanie De Cosse Avatar
    Stephanie D.
    2 years ago
    Im beyond happy with the services my daughter is receiving. Her therapist Lupe has done an amazing job, from keeping her entertained during her in-person and Telehealth visit. Staff is super friendly and very welcoming 🙂
    read more
    Ness M Avatar
    Ness M.
    2 years ago
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