Annual Parent Consent Form

Client's Name:*

First NameLast Name

Client's Date of Birth:*

Date

Who is the client's pediatrician/primary care physician (PCP)?*

Name of medical clinic:*

Location the client receives, or will receive, services at: (please check all that apply)*

School day therapy services are not covered by school tuition. Children’s Therapy T.E.A.M. independently bills and processes insurance. If I elect to receive school day services for my child, information about my child’s treatment and/or diagnosis will be shared with school employees who work closely with my child. If I prefer my provider not disclose information to school personnel, I may elect to independently seek out therapy services outside the school day. I understand that treatment during holiday breaks and summer breaks may be part of my child’s treatment plan.

I confirm my understanding.

The client is:*

NEWCURRENTRETURNING

Has there been a new diagnosis in the last year?*

YESNO

What is the new diagnosis?*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guardian's Name*

First NameLast Name

Relation to client*

Guardian's Date of Birth*

Date

Email*

example@example.com

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Which number should we use first?*

Cell PhoneHome PhoneWork Phone

Guardian's Place of Employement

Are there any additional guardians?*

YESNO

Guardian's Name

First NameLast Name

Relation to client

Guardian's Date of Birth

Date

Email

example@example.com

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Which number should we contact first?

HomeCellWork

Guardian's Place of Employment:

Who should we contact first?

List the FIRST & LAST NAME of ALL individuals authorized to pick-up.*

Name of Emergency Contact (other than parent or guardian)*

First NameLast Name

Emergency Contact Phone Number:*

Area CodePhone Number

Relation of the emergency contact (family friend, grandparent, etc):*

Is the client in foster care?*

YESNO

Caseworker Name:

First and Last

Caseworker Phone Number:

(xxx) xxx-xxxx

Does the client have an allergy?*

YES, the client has an allergy.NO.

Has this allergy been diagnosed as life-threatening?*

YESNO

What items cause an allergic reaction?*

How many times has the client had a reaction?*

OnceNeverMore than once

Please describe the client's reaction.*

When was their last reaction?

What has to happen for your child to react?*

What are the signs and symptoms of the client's allergic reaction?*

What is the plan of action you would like us to take if a reaction occurs? Please include administration of any medication such as Benadryl or an Epi-Pen.*

Do you authorize Children's TEAM to Administer Medication? If yes, please note dosage and reason for administration:

I authorization Evaluation, Treatment, and/or Delivery of Educational Services.*

YES

I authorize TeleTherapy treatment and/or educational services for the client at a distance using telecommunications technology.*

YESNO

Instructional Use Authorization to Photograph/Video*

YES, it is OK to photo/video the client for instructional use.NO, do not photograph/video the client.

Promotional Use Authorization to Photograph/Video*

YES, it is OK to photo/video the client and release on public platforms.NO, do not photograph the client.

May we leave voice messages which may contain patient health information?*

YESNO

I acknowledge and fully assume the risks related to the use of an aquatic environment. Some Children's TEAM locations have pools while others incorporate water-based activities.*

YES

I take responsibility for contacting my insurance funding source and for being fully responsible for charges not covered by insurance.*

YES

I am responsible for payment for evaluation services. Evaluations are comprehensive and include clinical evaluation and a thorough review of the client's medical history. I can expect to receive a copy of the evaluation report.*

YES

I authorize payment of medical benefits to be made directly to Children’s Therapy Services, Inc (DBA Children's Therapy TEAM, Children's ABA TEAM, The Grace School) for services rendered.*

YES

I will submit timely payments. I understand that failure to submit payments will result in a $50 fee. Additional fees up to 35% of the total balance may be incurred on delinquent accounts.*

YES

I will promptly report funding source changes, including loss of coverage, within 5 business days.*

YES

If my insurance company covers a set number of visits per year, I am responsible for keeping track of when my approved visits for the year will end.*

YES

I authorize the administration of first aid and/or CPR or contact of 911 as deemed necessary by staff.*

YES

I acknowledge that I have access to the Parent Handbook. I agree to follow the guidelines and policies set forth there in.*

YES

I acknowledge the status of Children’s TEAM as a teaching facility.*

YES

HIPAA (Health Insurance Portability and Accountability Act) Notice*

I have had an opportunity to read and review Children's TEAM's HIPAA Privacy Practice Notices.

Text Message Communication*

I understand the risks of unsecured text/email messages. If I elect to send an unencrypted text or email to my provider, I'm offering my consent for unsecured communications to and from my provider.

Terms & Conditions

You understand the risks of unsecured email/text which include, but are not limited, to: Messages may be forwarded, printed, and stored in numerous paper and electronic forms. Messages may be sent to the wrong address/number by either party. Messages may be easier to forge than handwritten or signed papers. Copies of email/texts may exist even after the sender or the receiver has deleted his or her copy. Service providers have a right to archive and inspect emails/texts. Messages may be intercepted, altered, or used without detection or authorization. Email may spread computer viruses. Delivery is not guaranteed. Email/text may be viewed by a third party.

You authorize treatment including physical therapy, speech therapy, developmental therapy, occupational therapy, orthotic equipment, ABA therapy, educational services, and/or communication device evaluation(s) and treatment for the client.

You authorize aquatic liability release and understand the assumption of risk. You acknowledge the risks related to the use of an aquatic environment to provide therapy, particularly the risk of drowning if a therapist for any reason becomes incapacitated while providing one-on-one therapy. You understand that this risk can be minimized with careful parent/caregiver supervision as there is no lifeguard on duty. You hereby, intending to be legally bound, for yourself, your heirs, assigned executors or administrators, waive and release forever all claims for damages against Children’s TEAM, its board of directors, instructors, therapists, aides, volunteers and/or employees, the pool owner, their board of directors, management, employees, aids and volunteers for any and all injuries and/or losses that you, assisting guardians, assisting caregivers and/or the client may sustain while in the aquatic environment for therapy (or any activity) provided by and/or sponsored by Children’s TEAM.

You take responsibility for communicating with your funding provider. By Authorizing Treatment, do you take responsibility for contacting your insurance provider/funding source to determine coverage. You agree to be fully responsible for charges, regardless of your insurance company/funding source coverage or lack of coverage of charges. Children's TEAM's policy limits the dates of backdated changes in claim or payment (insurance) information to 60 days prior to the date TEAM is notified of the change.

You authorize payment of medical benefits to be made directly to Children’s Therapy Services, Inc (DBA Children's Therapy TEAM, Children's ABA TEAM, The Grace School) for services rendered. You agree to either fully pay or set up a payment plan and begin payment for all charges within 30 days of the receipt of the statement.

You agree to be ultimately responsible for paying for services rendered, including claims not processed by your insurance within 90 days.

For Grace School students ONLY, educational services are not covered by insurance. Automatic deductions through ACH are required for tuition payment of educational services rendered.

You agree to promptly report funding source changes, including loss of coverage, within 5 business days to the Children’s TEAM billing team at 479-319-2755, regardless of the status of the receipt of an insurance card. Delays in providing updated insurance and payment information to Children’s TEAM may result in denial of coverage by funding sources.

You understand that funding sources may track visit counts. You agree that if your insurance company covers a set number of visits per year, you are responsible for keeping track of when your approved visits for the year will end. (Parents are welcome to call our billing office at any time to get a current visit count.) All non-covered visits, including visits that exceed annual allowed visits, will be billed at the out of pocket rate or insurance allowable rate.

You authorize the administration of first aid and/or CPR or contact of 911 as deemed necessary by staff in serious medical emergencies. Employees of Children’s TEAM will contact you as soon as possible to inform you of a medical emergency.

You acknowledge the status of Children’s TEAM as a teaching facility. Students periodically observe operations and treatment sessions. Additionally, services may be rendered by graduate student clinicians (those completing fieldwork as part of a graduate program in PT, OT, ST, ABA or DT) under the direct supervision of a licensed therapist. You can request to limit the scope of student interaction through notifying the treating therapist.

If you elected to give Children’s TEAM the right and privilege to photograph/video the client for the use of developing and publicly releasing promotional information, you understand that the client's image may be viewed in the form of magazines, picture slideshows, posters, television, commercials, social media, and/or other electronic media.

If you elected give Children’s Therapy TEAM the right and privilege to photograph/video the client for educational and instructional purposes, you understand that videos and/or photographs of the client may be viewed and discussed during instructional classes (sometimes web-based), in medical journals/e-journals, in medical books/e-books and on instructional posters/e-posters.

If you elected TeleTherapy treatment and/or TeleEducation, you understand that it is delivered at a distance using telecommunications technology. Even if not used exclusively, TeleTherapy can be beneficial if road conditions are hazardous, there are infectious illness concerns, etc. Consent to treat through TeleTherapy is voluntary and may be refused.

During TeleTherapy the client is not in the same location as the therapist/teacher. While facilitating the client's session, the therapist/teacher may be at a clinic, school, their home residence, or other private, self-contained location. The parent is responsible for contacting the insurance provider/funding source to determine eligibility for TeleTherapy/ TeleHealth/ TeleMedicine/ TeleBehavioral health. However, the parent is ultimately responsible for payment for services rendered.

There are potential risks to TeleTherapy technology, including interruptions, unauthorized access and technical difficulties. You use your own technology to connect with the provider, and are solely responsible for paying fees associated with my WiFi connection, cellular data, electricity, equipment, and supplies.
If you use a remote location, other than your home, you are responsible for all associated fees which are billed separately.

Either care provider or the parent can discontinue TeleTherapy/TeleEducation if it is felt that the videoconferencing connections are not adequate for the situation or for any other reason.

Some or all parts of the client's TeleVisit may involve contact with an individual (caretaker or parent) at the client’s location at the direction of the therapist/teacher. A caretaker/parent must be present at all times during TeleTherapy/TeleEducation. TEAM is not responsible for the client’s safety and basic care during, before, or after TeleTherapy/TeleEducation.

It may be necessary for others to be present during TeleTherapy other than the client's care team if assistance is needed for operation of video equipment. These individuals are bound to maintain confidentiality of all information obtained.

Parent Name (Sign below to consent to the terms and conditions stated above.) *

Parent Signature

Children's T.E.A.M. Annual Parent Consents

Next: Complete HIPAA Authorization, but first please 'SUBMIT' below. Thank you!