Questions answered in this article:
The Edit Consent Template found within the left side navigation bar Practice Setup - Website is currently DISABLED for updates and feature development based on the requests of the Therabyte community. We have provided a current solution below.
At this time you can attach your Consent Form to a Note then securely share it to your Clients Portal or choose the Email option.
Here are the instructions:
Example of Consent for offering pediatric services:
Consent and Payment Agreement Date:___________________
I, _________________________ (Parent/Guardian name) confirm that
___________________________(Child’s name) was born _____________________
Month/ Day/ Year
and agree to the following:
- I consent to my child receiving Type of Therapy services from Practitioner/Clinic and I will participate to my capability along with my child in the therapy services provided.
- I will disclose any medical reason why my child’s participation in these services might be limited.
- I will work collaboratively with the therapist to address behavioural issues that affect the outcome of therapy sessions. If required and/or if behavioural services are involved there will be a behaviour plan that is adhered to.
- I agree to have myself and/or my child’s picture/video taken. Any pictures/videos taken are for the sole purpose of the testing and will only be used for assessment or treatment/rehabilitation. Unless permission is otherwise granted.
- Practitioner/Clinic is permitted to release and obtain information from the following professionals involved in my child’s rehabilitation journey. This authorization is in effect until therapy sessions are concluded. Eg. Past OT, SLP, BC, Teacher, Daycare worker
Check all that apply
- Therapy services are billed at a rate of $1xx/hr for the session. Session billing is an inclusive fee for the time associated with the session to prepare and follow up via email.
- Additional Travel fee: for home visit is $xx
- Additional time is billed at $1xx/hour for agreed upon services. This may include: equipment sourcing, completion of a justification for equipment, team and phone meetings, planned phone call appointments including parent support, written assessment and progress reports, and material preparation requested specifically for your child.
- Missed appointments or cancellations.
- _____ I understand that I will be billed when a cancellation occurs within 24 hours of the scheduled appointment time. (I understand that the practitioner will do their best to use this time to work on my child’s file.)
- _____ If a third party is paying for therapy services, I agree to facilitate that payment be made directly to the therapist. (eg. AFU, AHP)
- _____ I understand that should the third party not reimburse the full cost of the therapy services, I remain responsible for those costs.
- _____ Private pay services, I agree to pay within 2 weeks of receipt of monthly invoice via e-transfer, cash or cheque. (Payable be to etransfer to firstname.lastname@example.org).
____I have read, understood and agree to the above terms as evidenced by my signature.
Name of Client
Name of Parent/Guardian