If you answered "yes" to the above question, please provide the clinic with a copy of the results if you have not already done so. If you answered "no," you will have to get a hearing screening completed before your child can be scheduled for an evaluation.
Permission Slip, Indemnification, Medical Agreement and Grant of Rights
I hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Clinic ("clinic"). I understand that the clinic is completely voluntary. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this clinic. I agree to indemnify and hold harmless TLC Group from and against any and all claims, demands, expenses, losses and liability arising out of personal injuries or death to any person or the damage, loss or destruction of any property which may occur or in any way grow out of any act or omission by my child or any and all costs, expenses and/or attorney fees incurred as a result of any claims, demands, and/or causes of action, through, or under my child which may arise as a result of his or her participation in the clinic.
If any emergency medical procedures or treatments are required during the clinic, I hereby consent to the staff of TLC’s clinic, arranging for, or consenting to the procedures or treatment in his, her, or their discretion. The only time a decision will be made in regard to serious illness or accident will be when extenuating circumstances prevent direct contact with parents/guardians regarding the matter.
By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, INDEMNIFICATION, MEDICAL AGREEMENT and GRANT OF RIGHTS. I have reviewed and read this agreement. The terms and conditions were explained to me in full, and I understand its terms and conditions. I have been given ample opportunity to review this agreement with an attorney of my choosing. My signature below is voluntary. I further certify that I am of full legal capacity to execute this authorization.
The Undersigned expressly agrees that the foregoing Release, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Louisiana and that if any portion or portions thereof shall be held invalid, it is agreed that said portion shall be severed from this Agreement and the balance shall, notwithstanding, continue in full legal force and effect.
Out of the Office Therapy Service Fee
Therapeutic Learning Center is happy to see your child at school. The fee for out of office sessions is ten dollars ($10.00) for each visit/evaluation a child is seen at school or other location outside of our clinic, regardless of the appointment length (30 min, 45 min, or 60 min). This fee will be added to your co-pay or private pay fee.
I agree to be charged for the out of the office therapy visit fee for every visit my child is seen at school or location outside of the TLC clinic.
I agree to place a credit card on file with the TLC administrator so that my child's services can be charged following each visit.
12 Week Therapy Session Duration/No-Show/Cancellation Policy
Please read this carefully.
12 Week Therapy Session Duration
As of January 1, 2019, Therapeutic Learning Center will be changing the way we provide our therapy sessions in regards to the duration of services. We will be providing therapy in 12 week intervals. At the end of 12 weeks, you will meet with your therapist to discuss your child’s progress, attendance (see below for the 75% attendance requirement), and together, determine whether continued services will benefit your child.
We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable; however, advance notification allows us to fulfill other client’s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 30, 45 & 60-minute treatments, missed appointments are a significant inconvenience to your occupational therapist, the clinic, and other clients. For the benefit of our clients and to optimize our therapist’s time, advanced notice for cancellations is requested.
We reserve your child’s therapy appointment times on a one to one basis. As a clinic policy, we do not double-book our clients so that we may provide optimum treatment for all our clients. We require 24-hour notice for all cancellations as it allows us to place another client in your cancelled appointment period to receive needed treatment. If the appointment is not cancelled outside of 24-hours, your appointment will be considered a “no show” and a $50 no show fee will be reflected on your account. We require a 75% attendance rate to keep your weekly appointment time. If the appointment can be rescheduled within the week, the missed appointment will not count against your attendance rate. We will allow for one “pass/missed appt” if the appointment is not cancelled outside of the 24 hours if your child is sick and missing the appointment is unavoidable.
After missing two consecutive appointments without notice or if you fail to maintain the 75% attendance rate, we reserve the right to place your child on a “stand by list” and services will be placed on hold or discharged.
Thank you for providing our office and our clients with this courtesy. Signing below indicates you understand and agree to the terms of this policy.