Authorization for Credit Cards

Clinical location

Client's Name (required)

Name on Card (required)

Billing Address (required)

Email (required)

Credit Card Type (required)

Credit Card Number (required)

Credit Card Expiration (required)

Credit Card Identification Number (required: last 3/4 digits located on the back of the credit card)

Amount to Charge: (specify if there is a deductible to meet)

Amount to Charge: ($30 Last Minute Cancellation/no show Fee - Please remember to cancel with notice (at least 12 hours prior to session) so that you are not charged a late fee.)

I authorize DV Therapy Inc to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder
agreement.

Cardholder – Please Sign and Date

Signature: Type out name as your signature (required)

Date (required)

Accept Terms (required): Click here for our terms

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
Attn: Iddo DeVries M.S. CCC-SLP
1080 S La Cienega Blvd Suite 208
Los Angeles CA 90035
File a grievance with the Secretary of the Department of Health and Human Services:
200 Independence Avenue, SW
Room 509F
HHH Building
Washington, DC 20201
[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 them
SPEAK UP when you have concerns
EXPRESS YOUR APPRECIATION when you are satisfied with your treatment

					We LOVE DV Therapy Palmdale! My son has Autism and gets Speech. He was getting Occupational Therapy services and has since graduated with the help of Ms.Alyah! Ever since he started there has been a HUGE improvement in his speech and fine motor skills. My child loves going to his therapies here and gets excited when he sees his therapists! It’s such a nice feeling knowing he likes the people there and wants to go back week after week. The staff here are very professional and you can see that they really care about your child. Ms.Amber is great and really takes in mind what my child interests are and turns it into speech opportunities! We are so grateful for all the amazing support from DV Therapy Palmdale!
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Nicholas V.
2 months ago
					Dv therapy is amazing. Staff is wonderful and so helpful. My little has been going for 2 years and has shown so much progress. Thank you to the wonderful ladies working with him.
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Reanna S.
2 months ago
					My kiddo started here when she was a little over two years old. Bronti and Hava have helped her developed her speech in just a matter of months and my daughter continues to expand her vocaulary daily.
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Sabrina L.
3 months ago

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