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.
I give consent I do not consent
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, please provide language needed No, I would like to opt out of interpreter services
Please check the appropriate therapy service:
ABA Therapy: ABA therapy is an intervention service that focuses on applying evidence-based techniques and strategies to reduce challenging behaviors, teach functionally appropriate behaviors, and develop skills such as communication, socialization, and forms of self-management. Any client receiving ABA therapy receives an individualized treatment plan that focuses on their specific areas of need. DV highly recommends parent involvement, an ABA treatment plan will also include hours for caregiver education/training and designated goals for caregivers to meet during a service period.
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 my child to receive these services.
I have read and agree to abide by the Consent to Treatment set forth by DV Therapy Inc.
Parent Name:
Client Name:
Date
Parent Signature
VIDEO RELEASE FORM
DV Therapy has permission to record my child's therapy sessions. The video recording will be used for training purposes and will be useful for ensuring quality treatment services for your child. 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
PHOTO RELEASE FORM
DV Therapy has my permission to use mine and/or my child’s 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 such use. I give consent I do not consent
MAKE-UP SESSIONS
Cancellations on the part of the provider (DV Therapy) or Client may occur during a service period. In order to ensure that a client receives all recommended hours for ABA services, scheduling make-up sessions is crucial to accomplishing this goal. In the event of a provider cancellation (i.e., DV therapist cancels), DV will make attempts to provide an alternative therapist to hold the session at the originally designated time. In the event of a client cancellation (e.g., client is sick), DV will offer dates to make-up the therapy session. In this scenario, the therapist available may be an alternative therapist. I will accept an alternative therapist when my therapist is absent. I will accept an alternative therapist when a make up session is required due to a
participant cancellation. I agree with the above statements
Shadow Therapist
DV Therapy Inc fosters a learning environment for new behavior technicians. One such way this is accomplished is by having them "shadow" a session to build on their therapy skills. A "shadow" may observe a session or be given opportunities to interact with a client under the guidance of the behavior technician or ABA Supervisor. 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 an “in-valid” cancellation.
As a courtesy, the Scheduling department sends out a confirmation text on the first day of the week (typically monday’s unless a holiday occurs) before the session – if the front office does not hear back that the sessions are confirmed, or prior alternative arrangements have been made, the office will assume that the sessions for the week is confirmed. Please make a point of confirming with the office so there is no confusion regarding the scheduled session.
DV’s minimum attendance policy is for clients to receive 80% or higher of scheduled sessions per month. If a client is under this threshold, steps will be taken to address the barriers. Please review the following for information on what is considered a “valid” reason for cancelling a scheduled therapy session. A valid cancellation will not be calculated into the minimum attendance policy.
Valid Cancellation
The following is a list of “Valid” reasons for a client cancellation:
The client is experiencing sickness such as fever, green/yellow mucus or discharge from mouth or nose, vomiting, diarrhea, or rash
Client has a scheduled doctor appointment
Family emergency such as death in family or other crisis
See below for DV’s COVID-19 Protocol
Any other reason for cancelling a session that is not listed above would be considered an “in-valid” cancellation. DV is understanding that emergencies or other life events can occur that at times is out of the hand of the parent/caregiver; however, DV considers the therapy services to be crucial to the client progressing. Please review the following for penalties that will occur when persistent “in-valid” cancellations accrue.
Verbal Warning:
If 10% or more of scheduled sessions are cancelled due to “in-valid” reasons in a calendar month (e.g., 2 out of 20 sessions in a month), the parents/caregivers of a client will be provided with a verbal warning. The verbal warning will be provided in writing and will require a signature from the caregiver/parent to confirm receipt of the verbal warning. DV will make attempts to determine if the schedule for the client needs to be adjusted to ensure cancellations will not occur.
Second Verbal Warning:
If 10% or more of scheduled sessions are cancelled due to an “in-valid” reason for a second month, within a 6-month authorization period, a second verbal warning will be provided to the caregiver/parent. A behavior contract will be made which will detail objective goals for attendance that the caregiver/parent will abide by for a designated time period. The behavior contract will be signed by the caregiver/parent.
Example Behavior Contract:
To the caregivers of (Client’s Name),
DV’s minimum attendance guideline is for client’s to maintain 80% of their scheduled therapy sessions each month. DV understands that there can be numerous reasons to have to cancel a scheduled session, this can include sickness, scheduling conflicts, or family emergencies. At this time, (Client’s Name) has been unable to maintain the minimum attendance guidelines. Which means that a number of “in-valid” cancellations have accrued to exceed the 80% threshold in (Month/Year). Below is the objective scheduling goals:
For the next two months (December 2021 and January 2022), (Client Name) will attend 90% of scheduled sessions. This requires no more than 2 “in-valid” cancellations, per month, per 2 consecutive months.
If (Client Name) is able to adhere to the contract, (Client)’s behavior contract will be removed and if another instance of a minimum attendance policy occurs, the penalty process will begin at the first verbal warning.
If (Client Name) is unable to adhere to the contract, a second behavior contract will be developed to ensure DV’s minimum attendance policy is followed.
Breaking of Behavior Contract:
If the objective goals set in the initial behavior contract are broken, the client may be subject to having a reduced therapy schedule. A second behavior contract will be made and signed by the caregiver/parent. A second behavior contract will have stricter goals (e.g., 95% attendance per month, per 2 consecutive months).
Breaking of Second Behavior Contract:
If the second behavior contract is broken, the client will be discharged from ABA services with DV therapy. This is due to the client being unable to attend consistent scheduled therapy sessions as clinically recommended and approved for by the insurance provider.
I have read and agree to abide by the Cancellation Policy set forth by DV Therapy Inc.
Parent Name (required)
Client Name (required)
Date (required)
Parent Signature (required)
COVID-19 Protocol:
As of January 12, 2022
DV Therapy Inc continues to uphold a strict COVID-19 protocol by implementing the following guidelines:
Please read and click “Agree” that you understand the measures being taken.
At this time we will not be able to see both vaccinated and unvaccinated individuals in-clinic if any of the following questions are responded with “yes.”
If you, or someone in your home has had flu-like symptoms in the last 7 days?
If you have travelled domestically/internationally within the last week
Due to the increased spread of the Delta Variant, we are requesting that all individuals who have travelled within the last week must take a COVID PCR Test after the 3-5th day of return and have a negative test.
If you do not want to provide a COVID PCR Test, we require you to quarantine and switch over to teletherapy for the next 10 days after your last day of travel.
If you, or someone who have been in contact with, tested positive for the coronavirus - quarantine for 10 days.
If you, or someone you have been in contact with, has had a fever - according to CDC guidelines, anything over 100.4 - in the last 7 days
**If during the time that you resume in person session, your answer becomes YES to the above questions - please contact our staff immediately to place in person services on hold.
We are continuing to offer teletherapy services - if you would like to continue being seen via telehealth, please reach out to our staff.
Client Contact
I 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!
