Child Occupational Therapy Form

In order to help us provide the best possible services to you and your child, please complete the following information.

We are pleased to provide your therapeutic services. It is our goal to provide the most effective and family-centered treatment as possible. Comments regarding your experience with our practice are always welcome. This information helps us meet your individual needs and maintain quality services for our clients.
CLIENT SERVICE AGREEMENTS We have found that clarity at the beginning of a clinical relationship fosters a good working partnership. In order to prevent confusion or misunderstanding regarding our policies and procedures, READ AND RETAIN the following information for your reference.
Family involvement: We highly encourage parents to be an active participant during the sessions. During or at the end of the sessions, parents/caregivers will be instructed on how to carry over lessons, implement homework, and activities throughout the week. Parent training/coaching will be provided for tips and insights. Parents are required to complete home program activities.
Discharge planning: The exit criteria for discharge may be due to one of the following reasons: poor attendance, reached age appropriate function, progress with therapy has plateaued, not able to participate in skilled therapy due to lack of attention/behavior, or due to parent’s request. In the event that a client has to be discharged due to noncompliance with treatment recommendations, the plans will be discussed with the clinician and the family/legal guardian.
Behavioral health: Our clinician’s safety is very important. If the client presents with inappropriate behaviors that interfere with the therapy and puts the clinicians in any danger, services may be placed on hold or terminated until a plan of action is proposed with the parent, office manager, and/or the supervisor.
Supportive community services: Our therapists will provide family members with supportive community services that may benefit the client.
Right to refuse services: DV Therapy Inc respects and protects their staff members against any aggression made toward staff whether verbally or physically. As such services will immediately stop for a client, if our staff is disrespected by the client, caregivers, or guardians.
You may reach the office by calling twenty-four hours a day. Our administrative hours are Monday - Friday, 9 am - 5pm. If there is no one available to answer your phone call, please leave a message and we will return your call promptly. Any call after administrative hours will be returned the following day.
Main office number: 323-426-6402 Email: [email protected]
The client is responsible for all payments due at the time of service.
We are in network with a number of insurance companies and government sponsored programs. For any insurance that DV Therapy is ‘in network’ with, we will bill the insurance company directly. Please note that if your deductible has not been met, you will be responsible for the full amount at time of service. If there is a denial from the insurance, you will be responsible for the full payment once we receive the denial.
For all others, we will bill the client directly, giving the family the opportunity to work with their own insurance companies to seek reimbursement. We will provide the client with receipts and invoices, which will list diagnosis and procedure codes as required by insurance companies.
We highly recommend that all families check with their insurance companies to review coverage details before agreeing to begin therapy with us
We accept the following forms of payment:
-Checks made out to “DV Therapy” - Cash -Credit Cards
DV Therapy Client Service Agreement- 2020 2
Thirty days notice will be given in advance of any fee increases for treatment services.
Evaluation sessions last 1-1.5 hours.
OT rates
Therapy: $130 for 30 mins
Therapy: $260 for 60 mins
Evaluation: $90 for every 15 minutes

ST rates
Therapy: $75 for 30 mins
Therapy: $150 60 mins
Evaluation: $300 hr

Evaluations include some or all of the following depending on the age and needs of each child:
● Standardized Articulation Assessment
● Oral Motor/Feeding Evaluation
● Phonological Processes Inventory
● Vocabulary Inventory
● Reading Fluency Assessment
● Reading Comprehension Assessment
● Stuttering/Fluency Assessment
● Social Skills Evaluation and Observation
● Parent Questionnaire/Developmental History
● Parent/Teacher Interview
When DV Therapy has not conducted the speech-language evaluation for your child, we REQUIRE that you provide us with a copy of the outside evaluation report, completed within the last six months, before we can begin treatment. We cannot ethically begin therapy without an evaluation.
Sessions are carefully pre-planned for your child. Your child will work directly with the therapist for the bulk of the session, leaving 10 minutes at the end to talk with the parent and/or write a brief treatment note. Please be considerate of the therapist's schedule as he/she may have another session following yours. If you require an extended conversation with your speech therapist, you may schedule a time for a meeting or phone conference.
Carry-over of treatment goals and progress into your child’s natural environment and routine is critical for maximum progress. For parents who are not able to participate in sessions, a communication plan should be determined directly with the therapist at the start of treatment and modified as needed during the course of treatment. Options include email, notebooks, multi-media messaging, and/or meetings.
When observing/participating in a treatment session, we would appreciate your consideration in the following:
• Please minimize the amount of distractions during the sessions
• Please be considerate of time constraints by keeping post session conversations short.

Session lengths may vary from 30 minutes to 2 hours depending on each individual situation, so charges are based on the set rate; $75 30 minutes and $125 for an hour.
Group sessions are billed according to the length of session and number in the group.
Periodically it is necessary to participate in extensive case management activities, such as parent and school conferences, to assure proper coordination of and communication about services. Therefore, with parental notification, conferences with parents, teachers, and other professionals, school observations, and lengthy telephone consultations will be billed at the hourly rate. There is no additional charge for “routine” case management activities (planning, chart keeping, brief coordination calls). Supplementary testing and/or re-evaluations, conducted with parental permission, will be billed at the evaluation rate of $225.
Additional reports (other than Annual Treatment Summaries and/or Discharge Reports, which are written by the SLP) will be billed at the hourly rate. When you or your insurance company REQUEST ADDITIONAL REPORTS, you will be billed at the hourly rate.
We respect your confidentiality in all matters. If you would like us to release information about an evaluation and/or treatment to another agency or professional, please request our standard Release Form from the office. If you would like us to have prior records of your child, which are often very helpful clinically, please have the information forwarded to our office.
DV Therapy Speech Services keeps copies of evaluations, re-evaluations, session notes, and discharge reports for all clients. We provide clients with copies of all formal reports upon request. It is our policy to keep digital office copies of these formal reports for a period of 5 years after client discharge. After that time, the records will be removed from our database. You are encouraged to keep and store your own copies of formal reports for your permanent records.


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.

Please check the appropriate therapy service:

Speech Therapy: Speech therapy is an intervention service that focuses on improving a child'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)(Required)
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.


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 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

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.


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 willassume 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 your child is 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 the therapist is unavailable for the

If your child is being seen in a school, day care, or another off-site setting, IT IS THE PARENTS RESPONSIBILITY TO NOTIFY THE SCHEDULING DEPT, (323-426-6402) OF A CANCELLATION. Check your child’s field trip, special event, and vacation schedule to prevent a last minute cancellation. Please talk with your therapist prior to any session breaks to assure continuity of services, reschedules and to avoid cancellation charges.

As a rule, therapy sessions will not be conducted on Federal holidays unless a special arrangement has been made between you and your therapist.


This agreement must be signed and returned to our office prior to the commencement of treatment.

Child’s Name
MM slash DD slash YYYY
Parent's Name(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.

Relation to Client(Required)

5 star ratingI love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing... read more
Bianca C. Avatar
Bianca C.
10 months ago
My 2 year old son has been improving so much over the last few months & im very thankful for... read more
Stephanie De Cosse Avatar
Stephanie D.
1 year ago
Im beyond happy with the services my daughter is receiving. Her therapist Lupe has done an amazing job, from keeping... read more
Ness M Avatar
Ness M.
1 year ago
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