Client Service Agreement – Easter Seals

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.


You may reach the office by calling twenty-four hours a day. Our administrative hours are 9-5, clinic hours 8-7. 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:


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

Thirty days notice will be given in advance of any fee increases for treatment services.


Evaluation sessions last 1-1.5 hours Rate: $225

*Additional assessment time is billed per hour at $125

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 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 e-mail, 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)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

    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 give consentI do not consent


    I agree with the above statementsI do not agree


    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.


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

    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.

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