Adult Form

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.

Clinical location
—Please choose an option—Antelope Valley (Palmdale)Los AngelesSan Gabriel Valley (West Covina)Bakersfield

Is your primary language spoken English?
YesNo

If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
YesNo

If yes, please provide language needed

No, I would like to opt out of interpreter services
YesNo

Please check the appropriate therapy service:

Speech Therapy: Speech therapy is an intervention service that focuses on improving a one'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)Occupational Therapy: Occupational therapy can help improve their motor, cognitive, sensory processing, communication, and play skills. The goal is to enhance development, minimize the potential for developmental delay, and help families to meet the special needs of their infants and toddlers

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 to receive these services.

PHOTO RELEASE FORM

DV Therapy has my permission to use my 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
such use.
I give consentI do not consent

VIDEO RELEASE FORM

DV Therapy has my permission to record my 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 consentI do not consent

MAKE-UP SESSIONS

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

CANCELLATION POLICY

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 you are 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.

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)

Email (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.

Client Contact