DV Therapy | Client forms speech therapy for easter seals and regional center

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

I do not agree

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 THERE ARE TWO LAST MINUTE CANCELLATIONS within ONE MONTH – the client will be at risk of being RETURNED TO THE FUNDING SOURCE.

*As a courtesy, the scheduling department sends out a confirmation text two days before the session – if the office does not hear back that the session is confirmed, or prior alternative arrangements have been made, the office will assume that the session is cancelled. Please make a point of confirming with the office to ensure that there is no confusion in regards to 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, it will be considered a last minute cancellation – and the client will be in jeopardy of being returned to the funding source.
If there is an emergency, or your child is sick, and you must cancel last minute (within 12 hours of session) you will need to provide a doctor’s note or proof of emergency – otherwise it will be considered a last minute cancellation and the client will be at risk of being returned to the funding source.
Excessive cancellations - two or more last minute cancellations or cancellations that exceed 20% of approved authorization – and the client will be at risk of being returned to the funding source or placed on a service hold. If 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 client session, DV Therapy will try to find an alternate therapist and/or find a date for a reschedule.

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.

Client Name(Required)

First

Client Birthdate(Required)

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.

Parent or Guardian(Required)

First

Best Contact #

Your preferred Method of Contact:(Required)

Text

Phone

Emergency Contact

Is this the same as above?

Yes

Emergency contact name:

First

Emergency Contact #

Relationship to the client

First

Scheduling Make-ups

Primary Contact for Scheduling

First

Best Contact #

Preferred Day for Make-ups

First

Preferred Time for Make-ups

Address (required)(Required)

City (required)(Required)

Cell Phone

Occupation

Referred by

Physician Name

Physician Phone

Physician Address

Marital Status

Single

Widowed

Divorced

Married

Spouse's Name

Spouse's Cell

Who lives in the home?

What languages do you speak? If more than one, which one is your dominant language?

What was the highest grade, diploma, or degree you earned?

Speech, Language, Voice, Cognition, and Hearing History

Describe your speech-language-voice-cognition-hearing problem.

What do you think may have caused the problem?

Has the problem changed since it was first noticed?

Have you seen any other speech-language specialists? Who and when? What were their conclusions or suggestions?

Have you seen any other specialists (physicians, audiologists, psychologists, neurologists, etc.)? If yes, indicate the type of specialist, when you were seen, and the specialist’s conclusions or suggestions.

List any previous speech-language-cognition-voice therapies. What goals were targeted in these therapy sessions?

Are there any other speech, language, cognition, voice, or hearing problems in your family? If yes, please describe.

Medical History

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

Adenoidectomy

Asthma

Chicken Pox

Colds

Croup

Dizziness

Draining Ear

Ear Infections

Encephalitis

German measles

Headaches

Hearing loss

High fever

Influenza

Mastoiditis

Measles

Meningitis

Mumps

Noise exposure

Otosclerosis

Pneumonia

Seizures

Sinusitis

Tinnitus

Tonsillectomy

Tonsillitis

Vocal Problems

Other

Do you have any eating or swallowing difficulties? If yes, describe.

List all medications you are taking.

Are you having any negative reactions to these medications? If yes, describe.

Describe any major surgeries, operations, or hospitalizations (include dates).

Describe any major accidents.

Provide any additional information that might be helpful in the evaluation or remediation process.

Person completing form

Client forms speech therapy for easter seals and regional center

Speech, Language, Voice, Cognition, and Hearing History

Medical History

Primary care physician

Antelope Valley

Los Angeles

San Gabriel Valley

Bakersfield