Child Occupational Therapy Form

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

WELCOME TO DV THERAPY
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.
HOW TO CONTACT US:
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]

OUR SERVICES AND FEES
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.
COMPREHENSIVE INITIAL EVALUATION
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.

TREATMENT SESSIONS
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.

TREATMENT RATES
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.

REPORT FEES
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.
RELEASES OF INFORMATION
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.
RECORD KEEPING
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.

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(Required)

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)

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 my child to receive these services.

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

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.

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 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.

FINANCIAL RESPONSIBILITY AGREEMENT

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

FAMILY INFORMATION

Child’s Name

First Last

Birthdate

Age

Parent's Name(Required)

First

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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.

Relation to Client(Required)

First

Parent or Guardian(Required)

First

Best Contact #

Your preferred Method of Contact:(Required)

Text

Phone

Emergency Contact

Is this the same as above?

Yes

[group group-emergency]

Emergency contact name:

First

Emergency Contact #

[/group]

Scheduling Make-ups

Primary Contact for Scheduling

First

Best Contact #

Preferred Day for Make-ups

First

Preferred Time for Make-ups

Age (required) - Edad(Required)

Diagnosis - Diagnóstico

Mother’s Name - Nombre de la madre

Mother’s Occupation - Ocupación de la madre

Father’s Name - Nombre del padre

Father’s Occupation - Ocupación del padre

Address (required) - Domicilio(Required)

Telephone(s) (required) - Teléfono(Required)

Family Physician - Médico primario de cuidado

Physician Phone - teléfono

Other Treating Physicians/Clinicians - Otros médicos y clínicos

Phone (Teléphono)

Other Treating Physicians/Clinicians - Otros médicos y clínicos

Phone (Teléphono)

Prenatal and Birth History (Información prenatal y sobre el parto)

Were there any unusual conditions before, during or after the pregnancy that may have affected the pregnancy or birth? - ¿Hubo alguna circunstancia o condición inusual antes de, durante o después del embarazo que hubiera afectado el embarazo o el nacimiento de su hijo(a)

Was your child born after a full-term pregnancy? If not, after how many weeks? ¿Su hijo(a) nació a término del embarazo o fue prematuro? ¿Si fue prematuro, después de cuántas semanas nació?

YES

If so, How many weeks

How old was the mother at the time of birth? ¿Cuál era la edad de la madre cuando nació el/la hijo/a?

Did your child’s mother take any medications or undergo any medical procedures while pregnant? Did the mother experience any fever, bleeding, cramping or other health concerns during the pregnancy? ¿Tomó la madre del/de la hijo(a) algunos medicamentos y/o se sometió a cualquier tratamiento médico durante el embarazo? ¿Experimentó fiebre, hemorragia, calambres u otras urgencias médicas durante el embarazo?)

Were there any health complications before or after your child was born? Please describe your child’s mother’s general health and your child’s general health at, prior to, and after birth. ¿Hubo complicaciones durante el embarazo o después de que nació su hijo(a)? Por favor describa el estado de salud de la madre del hijo y del hijo(a) antes de nacer, al nacer, y después de nacer.

Motor Milestones and Language - Hitos Motores y del Lenguaje

At what age was your child able to do each of the following: ¿A qué edad pudo hacer lo siguiente su hijo(a)?

Sit (Sentarse solo(a)

Crawl (Gatear)

Walk (Caminar)

Self-feed (Comer solo(a)

Name simple objects (Nombrar objetos)

Answer simple questions (Contestar preguntas sencillas)

Engage in conversation (Mantener una conversación)

At what age did your child say their first word? ¿A qué edad dijo su primera palabra su hijo(a)?

From any of the above milestones, has your child lost a previously acquired milestone or skill? If so, please explain. De los hitos anteriormente mencionados, ¿ha perdido su hijo una habilidad previamente adquirida? Si la respondió que sí, por favor explique.

Does your child have difficulty running, walking or participating in other activities that require small or large muscle coordination? ¿Tiene su hijo(a) dificultad con correr, caminar o participar en otras actividades que requieren la coordinación muscular?

Has your child ever had any feeding problems (e.g., problems with sucking, swallowing, chewing)? If yes, please describe. ¿Ha experimentado su hijo(a) problemas alimentarios; p.ej., problemas con mamar, tragar, masticar o babear? Por favor descríbalos.

How many words does your child know, and can speak, sign, or express by other communication methods (ex. pictures)? ¿Cuántas palabras sabe su hijo(a) y puede decir, señalar o expresar usando otras formas de comunicación (por ejemplo: usando retratos)?

Please describe any observations you have concerning your child’s ability to speak and communicate. Por favor describa sus observaciones al respeto a la capacidad de hablar y comunicarse de su hijo(a).

What is your child’s primary means of communication? Does your child use assisted communication? Please describe. ¿Qué es el medio principal de comunicación para su hijo(a)? ¿Su hijo(a) utiliza comunicación asistida? Por favor, describa.

Medical History (Historial Médico)

Has your child had any surgeries or hospitalizations? Please describe any major hospitalizations or accidents. ¿Ha tenido su hijo(a) cirugías o hospitalizaciones? Por favor describa cualquier hospitalizaciones o accidentes serios.

How is your child’s health currently? Do you have any health or medical concerns? ¿Cómo está la salud de su hijo(a)? ¿Usted tiene preocupaciones sobre la salud de su hijo(a)?

Is your child currently on any medications? If so, why, how long, and what dosage? ¿Su hijo(a) está tomando algún medicamento? Si es que sí, ¿Por cuánto tiempo y que dosis?

Does your child have any allergies/has he or she experienced any allergic reactions to medications? If “Yes”, please list them below. ¿Tiene su hijo(a) alergias o alguna vez ha experimentado una reacción alérgica al medicamento? Si respondió que “Sí”, por favor anótalas.

Does your child have frequent ear infections or allergies? If “Yes”, please list them below. ¿Tiene su hijo(a) infecciones de oído o alergias? Si respondió que “Sí”, por favor anótalas.

Has your child’s hearing been checked? If yes, describe the results. ¿Le han dado un examen auditivo a su hijo(a)? Si respondió que sí, describa los resultados.

Is your child on any type of special diet? If “Yes”, please describe it. ¿Su hijo(a) tiene algún tipo de dieta especial? Si respondió que “Si” por favor descríbala.

Does your child have any current medical conditions? If so, please include: known medical condition, dates and providers of previous treatment, current treatment clinicians, and current therapeutic interventions and responses. ¿Su hijo(a) tiene un condición médica de presente? Si respondió que “sí” por favor incluir el nombre de la condición médica, datos y proveedores de tratamiento del pasado y de ahora, y intervenciones y las respuestas.

Statement of Concern (Declaración de preocupación)

Describe in your own words your concerns about your child’s development. Describa en sus propias palabras sus preocupaciones sobre el desarrollo de su hijo(a).

Describe your child’s speech/language problems. When was the problem first noticed and by who? Describa los problemas del habla o lenguaje de su hijo(a). ¿Cuándo fue notado el problema y por quién?

What do you think may have caused the problem? Has the problem changed since it was first noticed? ¿Tiene Ud. idea de la causa del problema? ¿Ha cambiado el problema desde que se notó?

Is your child aware of the problem? If yes, how does he/she feel about it? ¿Está consciente del problema su hijo(a)? Si respondió que sí, ¿cómo se siente él/ella acerca del problema?

Have other specialists seen your child? If yes, what type of specialists and when? ¿Otros especialistas han examinado a su hijo(a)? Si respondió que sí, ¿qué tipo de especialistas y cuando?

What were the conclusions or suggestions of the specialists? ¿Cuáles fueron las conclusiones o sugerencias de los especialistas

What are your child's strengths (e.g., sense of humor, enjoys reading, a good swimmer, creative)? ¿Cuales son los puntos fuertes de su hijo(a) (por ejemplo, tiene buen sentido del humor, disfruta leer, es un buen nadador, es creativo(a)?

Educational Information (Información Educativa

What is the name of your child’s school? ¿A cuál escuela asiste su hijo(a)?

What grade is your child in? ¿En cuál grado está su hijo(a)?

What type of class is your child in (e.g., general education, special education, special day class, etc.)? ¿En cuál tipo de clase está su hijo(a) por ejemplo, educación general, educación especial, clase especial de día, etc.)?

If enrolled in special education services, has an Individualized Education Plan (IEP) been developed? If yes, describe the most important goals. Si su hijo(a) recibe servicios de la educación especial, ¿se le ha desarrollado un Programa Educativo Individualizado (PEI)? Si respondió que sí, describa las metas más importantes del PEI.

How does your child interact with others (e.g. is he/she shy, aggressive, uncooperative)?¿Cómo se relaciona su hijo(a) con otras personas (p.ej., ¿es tímido(a), agresivo(a), poco colaborador(a)?

Does your child currently receive any therapy at school or outside of school (from regional centers/insurance companies/private pay)? If yes, what type and how often? ¿Su hijo(a) está recibiendo terapia en la escuela o afuera de la escuela (de un centro regional/ compañías de aseguranza/pago privado? Si respondió que “Si,” ¿qué tipo y con qué frecuencia?

Please list all prior therapies your child has received, including the dates, providers, therapeutic interventions, and responses. Incluya todas las terapias anteriores que ha recibido su hijo(a), incluyendo las fechas, los proveedores, intervenciones terapéuticas, y las respuestas

Please list all community resources you are currently utilizing ( i.e. support groups, social services, school based services, other social support). Incluya todos los recursos de la comunidad que está utilizando su hijo (p.ej. grupos de apoyo, servicios sociales, servicios de la escuela, otro tipos de apoyo)

Family Information (Información sobre la familia)

Names of Brothers and Sisters (Nombres de Hermanos y Hermanas)

Ages (Edades)

Any Concerns about their Development (Preocupaciones acerca de su desarrollo)

Does anyone in your family have any learning problems, developmental delays, mental health issues or neurological difficulties? Please describe. ¿Alguien en su familia tiene problemas de aprendizaje, retrasos en el desarrollo, problemas con la salud mental o dificultades neurológicas? Si respondió que sí, por favor anótalos.

Describe the mother and father’s level of education and any support services or special assistance they received (Speech, special education, tutoring, etc). Describe el nivel de educación de la madre y el padre, e incluya también cualesquier servicios de apoyo o asistencia especial que reciben o han recibido en el pasado (terapia del habla, la educación especial, la tutoría, etc.)

Who is currently living in the home with your child? Does he/she live with both parents? ¿Quien vive en el hogar con su hijo(a)? ¿Vive él/ella con su madre y su padre?

Are there any relevant legal issues of the client/family we should be aware of? ¿Hay algunos asuntos legales relevantes del cliente/la familia de que debemos saber?

What is the language spoken most often in your home? ¿Cuál idioma se habla más a menudo en su hogar?

What language(s) does your child speak? ¿Cuales idioma(s) habla su hijo(a)?

What language(s) does your child understand? ¿Cuales idiomas entiende su hijo(a)?

What is his/her dominant language? ¿Cuál es el idioma dominante de su hijo(a)?

Sensory Profile (Perfil sensorial)

Please describe your child’s responsiveness or sensitivity to the following sensory areas:

Por favor describa la reacción o sensibilidad de su hijo(a) a las siguientes áreas sensoriales.

Visual:(Visual)

Touch:(El tacto)

Auditory:(Auditorio)

Taste:(El gusto)

Physical/Motor:(Físico)

Does your child have ayn significant fears, such as fears or strangers, darkness, water, public speaking, etc.? Please describe ¿ Tiene su hijo/a temores significantes, como el temor de los extranjeros, la oscuridad, el agua, hablar en público, etc.? Si respondio que si, por favor anotelas.

Does your child have any unusual or repetitive actions, such as liking to spin objects, hand flapping, etc.: ¿Su hijo(a) hace algunas acciones repetitivas o inusuales? Por ejemplo, le gusta girar objetos o aletear sus manos?

Behavior information

Does your child currently have any behavioral health condition or intensive autism related services? If so, please include the dates and providers of previous treatment, and therapeutic intervention and responses. ¿Su hijo(a) tiene una condición de salud comportamental o

Does your child harm self or others? ¿A su hijo lastimar el mismo o los otros

Does anyone in your family have any history of behavioral health treatment? Please describe. ¿Alguien en la familia tiene una historia de tratamiento de salud comportamental? Por favor, describa.

Other information: What are your child’s favorite foods? ¿ Qué son los alimentos favoritos de su niño (a)?

What are your child’s favorite toys and games? ¿ Cuáles son los juguetes y juegos favoritos de su niño (a)?

What are your child’s favorite activities? ¿ Cuáles son las actividades favoritas de su niño (a)?

Does your child have any special or unique interests? ¿ Su niño tiene algunos intereses especiales o únicos?

What would you like for us to know about you and your child’s cultural and spiritual variables that may impact treatment? ¿Hay algo que usted quiere decirnos sobre la cultura o espiritualidad de usted o su hijo(a) que puede impactar el tratamiento?

REFERRING INFORMATION

Who referred this child/patient for an evaluation?

Reason for referral

What are you primary concerns/goals for therapy regarding your child/the patient?

What are you child’s/patient’s strengths?

Primary care physician

I have a primary care physician

Yes

[group group-physician]

Physician’s Name

First

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)(Required)

Yes

Patient's Date of Birth(Required)

Today's Date (required)(Required)

Signature: Type out name as your signature (required)(Required)

First

Accept Terms:(Required)

Accept Terms: Click here for our terms

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					<img decoding=async  src="https://mlzvkesrhmut.i.optimole.com/w:auto/h:auto/q:mauto/https://www.dvtherapy.com/wp-content/plugins/wp-review-slider-pro/public/partials/imgs/yelp_stars_5.png" alt="5 star rating" class="wprevpro_t1_star_img_file">I love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing... read moreI 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 less				
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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 moreMy 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 less				
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1 year ago

					Im beyond happy with the services my daughter is receiving. Her therapist Lupe has done an amazing job, from keeping... read moreIm 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 less				
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1 year ago