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Fill out the New Adult Client Registration

Adult Client Registration

  • Date Format: MM slash DD slash YYYY
  • Therapy Agreement

    The 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 Policies

    By checking the boxes below, I have read and agree to abide by the following policies.
  • Acknowledgement of Risk

    I 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.
  • 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 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.
  • Attendance Policy

    By 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.
  • Sick Policy

    By 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.
  • Emergency Medical Care Authorization

  • By checking the boxes below, I have read and agree to abide by the following policies.
  • Permission for Release

    To 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.
  • Please 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 Authorization

    Communication 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.
  • 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.
  • Emergency Contact Information

    In case of emergency, the following individuals have permission to make decisions regarding my well being.