Flower Header Image

Fill Out the Welcome Packet

New 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. We often have occupational therapy students at Emerge Pediatric Therapy for a level two fieldwork placement. These students have completed all of their course work and been interviewed by the clinic's Fieldwork Coordinator, 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 always continues to be involved in the therapy session and the child benefits from having the attention of two therapists, which often optimizes the treatment time. I give permission for current occupational and speech therapy students to observe and if appropriate participate in my child’s 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 child’s therapy.
  • Office Policies Regarding Siblings and Friends of Clients

    By checking the boxes below, I have read and agree to abide by the following policies.
  • Attendance Policy

    By checking the boxes below, I have read and agree to abide by the following policies.
  • The success we will achieve with your child depends on the consistency of treatment they receive. The appointment time that you agree to will be reserved for your child each week with the corresponding therapist. Our therapists put careful consideration and clinical judgement into planning your child’s therapy session, completing caregiver education, and tailoring recommendations to your child and family’s needs. We ask that you as a family make the same commitment to us and your child 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 child’s progress, we also understand that children get sick. We want to make the clinic a safe environment for your child and all our clients and staff. We ask that you adhere to the following guidelines in determining whether your child is 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 your child. We recommend that copies of evaluations and other written reports be shared with other professionals in your child’s life (i.e. teacher, pediatrician, psychologist, tutor, etc.). It is important for us to be able to maintain good communication with people working with your child. This release would remain in effect for one year and authorizes the clinic to send your child’s written reports and/or have verbal conversations to/with 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 child’s therapist about sessions, goals, and progress is crucial to your child’s 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.
  • Authorization for Child Pick Up

    Please list the names and phone numbers of individuals who are authorized to pick your child up from therapy sessions at Emerge Pediatric Therapy. The staff at Emerge Pediatric Therapy will ask for a photo ID from anyone who is picking your child up from the clinic.
  • Emergency Contact Information

    In case of emergency, and the Emerge Pediatric Therapy staff is unable to reach a parent/guardian, the following individuals have permission to make decisions regarding the care of my child, including granting permission to individuals to pick up my child from Emerge Pediatric Therapy.
  • It is important to us maintain the safety of all children at Emerge Pediatric Therapy. By checking the boxes below, I have read and agree to abide by the following policies.