New Client Registration Fill Out the New Client Registration New Client Registration Date* MM slash DD slash YYYY Child's Name* First Child's Name* Last Caregiver/Guardian's Name (First, Last)* 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 caregiver consultation, writing treatment notes and treatment planning, and setting up the clinic to tailor the environment to the child’s needs for the treatment session. A 45-minute session consist of 35 minutes of direct treatment. A 30-minute session consist of 25 minutes of direct treatment and 5 minutes for caregiver consultation, treatment notes and planning, and setting up the clinic for the treatment session. I understand that my child’s 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 child’s care, I may schedule calls or a meeting with my child’s therapist. I understand a fee for in-depth consultations (more than 10 minutes) will be added to my bill at the treatment rate, pro-rated 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. Families may cancel treatment if they 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 my child has received the maximum benefit from therapy. This will be determined by the Emerge Pediatric Therapy therapist in conjunction with the caregiver(s), 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. We often have occupational and speech 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 committed to training students to provide state of the art therapy to children. We often have occupational and speech 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. 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 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. Yes No Office Policies Regarding Siblings and Friends of ClientsBy checking the boxes below, I have read and agree to abide by the following policies. * I understand that young children often need to be accompanied by a caregiver during treatment; all other individuals are asked to remain in the waiting room. The caregiver library is for the use of adults only. I understand that I am responsible for waiting with my child in the waiting room until the session begins and for monitoring my child’s play in the waiting room. I understand that I am responsible for returning for my child 10 minutes before the close of the treatment session. If I leave during my child’s session, I am responsible for leaving contact information with the front desk, so that the clinic is able to contact me in the case of an emergency. I understand that progress report and/or goal updated are routinely written two times a year (every six months) or more frequently if desired, and caregiver treatment planning conferences are often scheduled at these times to discuss my child’s current abilities and continued therapy needs and to plan future treatment goals and objectives. I understand that the meeting will be billed at the hourly treatment rate and there will be re-evaluation fee charged. I understand that I need to provide notification of outside meetings or consultations at least three weeks in advance to allow our therapist to prepare and to coordinate meeting dates and times. I have read the above information and understand that, as a caregiver or guardian, I am ultimately responsible for payment of all services provided by Emerge Pediatric Therapy. Attendance PolicyBy 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.*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. I understand that I should arrive on time for the scheduled appointment. I understand that if I leave the clinic during the appointment time, I must be back at least 10 minutes prior to the end of the appointment. I may be required to remain in the clinic during future sessions if I am not present at the time caregiver education begins at the end of the session. If I leave the clinic during my child’s session, it is my responsibility to leave a reliable contact number where I can be reached by the front desk. 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 my child 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 child’s 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 the Emerge Pediatric Therapy policy and I am making the commitment to consistent attendance. 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 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.*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. Children should be free from fever, vomiting, or diarrhea without the use of Tylenol or Ibuprofen for at least 24 hours prior to their appointment. (A fever is considered to be a temperature at or above 100 ° F .) Children who are home from school 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 your child presents with one of these illnesses, do not bring him/her to therapy until the risk of transmission has passed. If your child is lethargic or unable to participate in daily activities due to an illness, please do not bring him/her to therapy. If your child develops a fever or falls ill during his/her appointment, we will end the session early. Please remain available/close by to pick your child up, if needed. If a sibling 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 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. * I hereby authorize Emerge Pediatric Therapy to release Occupational, Speech, and/or Physical Therapy reports of my child, 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 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.I hereby authorize Emerge Pediatric Therapy to leave messages regarding appointment changes and/or information from my child’s 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 PhoneAuthorization for Child Pick UpPlease 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. Name/Phone Number Name/Phone Number Name/Phone Number Name/Phone Number Emergency Contact InformationIn 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.Emergency Contact Person 1 (First, Last)* PhoneRelationship Emergency Contact Person 2 (First, Last)* PhoneRelationship 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.*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. I understand that it is my responsibility to inform the staff at Emerge Pediatric Therapy if someone other than myself will be picking up my child. I understand that Emerge Pediatric Therapy will contact me or my child’s Emergency contact if there is a question or concern regarding individuals picking up my child.
