Pediatric Treatment Qualification Contract

Patient Name

First NameLast Name

Parent Name

First NameLast Name

Relationship to patient

Thank you for your interest in our program! It is crucial for us to provide excellent quality and highly effective care with empathy and compassion. Most patients are used to an allopathic model of care, where the healing happens because an external device, procedure, or pharmaceutical brings about relief.

Our model is different by design. While we do use several technologies and procedures as part of our system, we believe that healing happens from the inside out. Each patient plays a critical role in his/her recovery. This is the case even if dealing with very young pediatric patients. To that end, every patient must be a good fit for our program. We have designed the following steps to help us discern if our program is a good choice and the right fit for you. Please understand that while we want to help every patient who applies to our program, a successful outcome is very important to you and our primary concern.

Please carefully read and initial the following statements. Explain each statement to your child and have him/her agree that they understand. If you or your child have any questions/comments, please use the space provided at the bottom and write those down.

I understand that treatment may require me to be active. It is not my mom/dad/guardian’s responsibility to ensure that I keep my appointments, nor participate in my treatment.

I understand

I understand that the staff at The Spero Clinic has treated many other children successfully. It is an important part of my treatment to follow my therapist and/or doctors’ advice and directions.

I understand

I will always treat the staff at The Spero Clinic with respect, even if I don’t feel well. I understand that they are doing their best to help me feel and function better.

I understand

While I may be scared at times and may have temporarily lost hope, I understand that my attitude is crucial to a positive outcome. I will maintain a positive attitude and expect to be healed once and for all.

I understand

The Spero Clinic’s program is not like any other pediatric pain program in the country. While some of my treatments may not be comfortable, they are all designed to make my body and brain function more efficiently, not simply get used to pain. Desensitization is NOT utilized at The Spero Clinic under any circumstances.

I understand

If it is found to be beneficial to my treatment, my parent may be asked to leave the room during my treatment with their permission.

I understand

If my behavior is impacting others at the clinic negatively, I may be asked to leave the program. Please do not put us in this uncomfortable situation by keeping your behavior positive.

I understand

If you have any questions/comments, please use the space provided and write those down:

___ /10 - On a scale of 1-10 with zero having no hope, and 10 being 100% hopeful, please rate how hopeful you are that your body and brain can recover:

Please write a short paragraph on why you believe that our program is a good fit for you:

Please use your own words to write a few sentences about how you will feel and how your life will be improved when you are healthy again and fully recovered:

Date

Signature

Pediatric Treatment Qualification Contract

Patients 12 years and older: