New Adult Client Registration Fill out the New Adult Client Registration Adult Client Registration Date* MM slash DD slash YYYY Client's Name* First * Last Preferred Pronouns* Therapy AgreementThe following is a description of Emerge Pediatric Therapy policies. Please read and indicate your agreement to abide by these policies by checking the box where indicated. If you have any questions about these policies, please ask a clinic representative before signing.Scheduling PoliciesBy checking the boxes below, I have read and agree to abide by the following policies. * I understand that a treatment session scheduled for 1 hour consist of 50 minutes of direct treatment. An additional 10 minutes is used for client consultation, writing treatment notes and treatment planning, and setting up the clinic to tailor the environment to the client’s ’s needs for the treatment session. A 45-minute session consists of 35 minutes of direct treatment and 5 minutes for client consultation, treatment notes and planning, and setting up the clinic for the treatment session.A 30-minute session consists of 25 minutes of direct treatment and 5 minutes for client consultation, treatment notes and planning, and setting up the clinic for the treatment session. I understand that my therapist can provide additional consultation time by ending a treatment session 5 to 10 minutes early or by scheduling a meeting or a phone conversation. If I desire a longer consultation for myself or other professionals involved in my care, I may schedule calls or a meeting with my therapist. I understand a fee for in-depth consultations (more than 10 minutes) will be added to my bill at the treatment rate, prorated for the amount of time provided. I understand that once a weekly treatment appointment schedule has been determined, this clinic is often unable to accommodate changes for temporary periods of time. When permanent change in time is needed, I must give as much notice as possible for the clinic to attempt to accommodate this request. A change in time may necessitate a change in therapist as well. I understand that the weather policy is as follows: the clinic is open except in cases of severe weather conditions requiring businesses to close. It is my responsibility to call the clinic to determine whether changes in the scheduled time of treatment are needed and if the opening of the clinic has been delayed. I may cancel treatment if I do not wish to travel because of poor road conditions. I understand that severe weather cancellations will not be charged a late cancellation fee. I understand that when our therapist is ill or on vacation, every effort will be made to provide another therapist to ensure continuation of services. This may require alternative appointment times. I understand that services will be terminated when I have received the maximum benefit from therapy. This will be determined by the Emerge Pediatric Therapy therapist in conjunction with my, physician, and/or teachers. Acknowledgement of RiskI acknowledge that there is some risk inherent in the use of the therapy equipment at this clinic and agree to indemnify and hold Emerge Pediatric Therapy harmless from any and all losses and claims for any injuries or other damages occurring to myself, my child(ren) or our belongings from the use of therapeutic equipment.* I have read and agree to abide by the above policies. Optional Educational Activities Please mark Yes or No for the following activities. If you mark no to either of the following, your therapist may approach you for permission if a need for the items occurs. Emerge Pediatric Therapy is committed to training students to provide state of the art therapy to children, adolescents, and adults. We often have occupational therapy students at Emerge for their final fieldwork placement. These students have completed all of their course work and one, 3-month fieldwork placement, before coming to Emerge Pediatric Therapy. These students are typically assigned to one therapist and participate in treatment with that therapist. The Emerge Pediatric Therapy staff therapist will always continue to be involved in the therapy session. In addition, we periodically have individuals observing who are interested in pursuing a career in speech or occupational therapy.*Emerge Pediatric Therapy is committed to training students to provide state of the art therapy to children, adolescents, and adults. We often have occupational therapy students at Emerge for their final fieldwork placement. These students have completed all of their course work and one, 3-month fieldwork placement, before coming to Emerge Pediatric Therapy. These students are typically assigned to one therapist and participate in treatment with that therapist. The Emerge Pediatric Therapy staff therapist will always continue to be involved in the therapy session. In addition, we periodically have individuals observing who are interested in pursuing a career in speech or occupational therapy. Yes No Emerge Pediatric Therapy is also committed to helping undergraduate students learn about occupational and speech therapy in preparation for applying to graduate programs. A therapist will periodically have an individual observing who is interested in pursuing a career in speech or occupational therapy. I give permission for prospective occupational and speech therapy students to observe and if appropriate participate in my therapy.*Emerge Pediatric Therapy is also committed to helping undergraduate students learn about occupational and speech therapy in preparation for applying to graduate programs. A therapist will periodically have an individual observing who is interested in pursuing a career in speech or occupational therapy. I give permission for prospective occupational and speech therapy students to observe and if appropriate participate in my therapy. Yes No Attendance PolicyBy checking the boxes below, I have read and agree to abide by the following policies. The success we will achieve together depends on the consistency of treatment you receive. The appointment time that you agree to will be reserved for you each week with the corresponding therapist. Our therapists put careful consideration and clinical judgement into planning you therapy session, completing education, and tailoring recommendations to your needs. We ask that you make the same commitment to us by attending the regularly scheduled sessions.*The success we will achieve together depends on the consistency of treatment you receive. The appointment time that you agree to will be reserved for you each week with the corresponding therapist. Our therapists put careful consideration and clinical judgement into planning you therapy session, completing education, and tailoring recommendations to your needs. We ask that you make the same commitment to us by attending the regularly scheduled sessions. I understand that I should arrive on time for the scheduled appointment. I understand that if I need to cancel an appointment, rescheduling is expected for continuity of care. I may be offered a reschedule time with another therapist, who will be trained to deliver the same quality of care that I expect. I understand that I must contact Emerge Pediatric Therapy if I am unable to keep my scheduled appointment. More than 2 “no shows” within a 3-month period will put me at risk of losing their reoccurring appointment and being placed on a “Flex Schedule.” “Flex Schedule” clients will contact the office to schedule their appointment on a weekly basis depending on openings on the therapy schedule. For out of network clients, a “late cancellation” is considered as any appointment that is cancelled with less than 48 hours notice. Late cancellations will be responsible for payment of half of the treatment session rate unless the session is rescheduled and attended within a week. For out of network clients, a “no show” will be responsible for payment for the full treatment session rate unless the session is rescheduled and attended within a week. For in network clients, I understand that while I cannot be charged a fee for “late cancelations” or “no shows,” my ability to continue services may be impacted by their attendance. For in network clients, I understand that if there are 3 late cancels within a 2-month period, my child’s reoccuring therapy time may be offered to another family who is waiting to begin services. I understand that if there are 3 late cancels within a 2-month period, my reoccuring therapy time may be offered to another client who is waiting to begin services. Sick PolicyBy checking the boxes below, I have read and agree to abide by the following policies. While regular attendance at therapy sessions is crucial for your progress, we also understand that people get sick. We want to make the clinic a safe environment for you and all our clients and staff. We ask that you adhere to the following guidelines in determining whether you are well enough to attend therapy.*While regular attendance at therapy sessions is crucial for your progress, we also understand that people get sick. We want to make the clinic a safe environment for you and all our clients and staff. We ask that you adhere to the following guidelines in determining whether you are well enough to attend therapy. The client should be free from fever, vomiting, or diarrhea for at least 24 hours prior to their appointment. (A fever is considered to be a temperature at or above 100 ° F .) If you are home from school or work because of an illness should not attend therapy. Please be cautious about highly contagious illnesses like pink eye, head lice, scabies, whooping cough, strep throat, hand foot mouth, ringworm, and chicken pox. If you present with one of these illnesses, do not come to therapy until the risk of transmission has passed. If you are lethargic or unable to participate in daily activities due to an illness, please do not come to therapy. If you develop a fever or fall ill during your appointment, we will end the session early. If a child or other family member is actively sick and/or contagious, we ask that you also refrain from bringing them into the clinic. Emergency Medical Care AuthorizationClient's Name* First * Last Client's Physician/Practice* Client’s Physician/Practice Phone Number* Hospital Preference* By checking the boxes below, I have read and agree to abide by the following policies.By checking the boxes below, I have read and agree to abide by the following policies. In the event of a medical emergency, I hereby authorize Emerge Pediatric Therapy employees to seek care for the client from the above named physician/practice or the closest hospital emergency room, if deemed necessary. In the event of a medical emergency, I hereby authorize Emerge Pediatric Therapy employees to call for an ambulance for transporting the client if necessary. In the event that I cannot be reached in an emergency situation, I hereby authorize the above named physician/practice to treat the client. In addition, emergency room physicians have my permission to treat the client if neither I, nor the above named physician can be reached. I understand that the bill incurred under this authorization is my responsibility. This authorization shall be valid for the time the client is an active client of Emerge Pediatric Therapy. I understand that this is voluntary and that my permission may be withdrawn at any time. Such withdrawn shall be submitted in writing to Emerge Pediatric Therapy and cannot be made to the extent to which action has been taken. Permission for ReleaseTo facilitate integrated service for you we recommend that copies of evaluations and other written reports be shared with other professionals in your life (i.e. teacher, physician, psychologist, tutor, etc.). This release would remain in effect for one year and authorizes the clinic to send your written reports to outside professions. * I hereby authorize Emerge Pediatric Therapy to release Occupational and/or Speech Therapy reports of my mine, to the agencies or professionals listed below. I hereby authorize Emerge Pediatric Therapy to have verbal contact to the agencies or professionals listed below. I DO NOT authorize Emerge Pediatric Therapy to communicate in writing or verbally to outside agencies/professionals. Agencies/ProfessionalsPlease list the names and complete addresses, phone numbers and/or fax numbers of agencies/professionals that you would like to receive copies of your child’s occupational/speech therapy reports. Phone and Voicemail AuthorizationCommunication with your therapist about sessions, goals, and progress is crucial to your success. Please authorize Emerge Pediatric Therapy to leave messages on both phone and email.I hereby authorize Emerge Pediatric Therapy to leave messages regarding appointment changes and/or information from my therapist.* Cell Phone Home Phone Email I DO NOT authorize any voicemails or emails Appointment Reminders*You may select to receive reminders via email, text message or both. Reminders will be sent out one day prior to each scheduled appointment. Appointment reminders may contain info such as patient first name and clinic name. Email only Text message only Both email and text message I DO NOT wish to receive appointment reminders Email Cell PhoneHome PhoneEmergency Contact InformationIn case of emergency, the following individuals have permission to make decisions regarding my well being.Emergency Contact Person 1 (First, Last) PhoneRelationship Emergency Contact Person 2 (First, Last) PhoneRelationship