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.
—Please choose an option— Antelope Valley (Palmdale) Los Angeles San Gabriel Valley (West Covina) Bakersfield
Is your primary language spoken English?
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
If yes, please provide language needed
No, I would like to opt out of interpreter services
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)
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
I give consent I do not consent
VIDEO RELEASE FORM
DV Therapy has my permission to record my child's therapy sessions. The video recording will be used for training purposes. It will not be made public and will have internal use only. Once the video is no longer needed, it will be deleted.
I give consent I do not consent
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
The following cancellation monetary policy does not apply to Regional Center, Kern Family, and Easter Seals clients.
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 will assume 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 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)
Client Birthdate (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.
Prenatal and Birth History (Información prenatal y sobre el parto)
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?
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)?
Medical History (Historial Médico)
Statement of Concern (Declaración de preocupación)
Educational Information (Información Educativa
Family Information (Información sobre la familia)
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.
[textarea screening placeholder "For clients 12 years and older, was a screening ever done for evidence of use or exposure to alcohol, nicotine, and/or illicit drugs? If yes, please explain. Para clientes de 12 anos o mas, habia una revisión para evidencia del uso o exposición a alcohol, nicotina, y/o drogas ilicitas? Si dijo que “si”, por favor describa. ]
Client Contact Consent for Treatment