Parental Agreement
This document includes 'ASD Health Coach' practice policies and guidelines set forth to allow me to best assist you with my services. Please read each guideline and type your full name in the response box below stating you understand, acknowledge and agree to the terms. Please sign your name at the bottom prior to submitting.
I understand that the role of a health coach is not to diagnose or prescribe, and does not replace or override medical advice from your child's practitioner/pediatrician.
I understand that a 30 minute appointment is required at a minimum of once every 4 weeks, OR a 60 minute appointment every 8 weeks to remain an active patient and continue to receive email access and support.
I understand that emails between appointments are intended to clarify questions/concerns pertaining to a current protocol or treatment plan.
I understand that emails should not be used as an open forum for discussion on matters not pertaining to the current treatment plan, protocol, or child's progress.
I understand that emails should contain simple, targeted questions that are able to be answered in 1-2 sentences each; not paragraphs. If further discussion is needed outside of that parameter, I understand I may be asked to schedule a 30 minute appointment when necessary.
I understand that the information and recommendations received from ASD Health Coach (Becky Davila) are tailored for my child's individual needs, and are intended only for myself (parent/caregiver) and should not be shared with others or posted on social media without permission from Becky beforehand.
I understand that ASD Health Coach (Becky Davila) may not be available to respond to emails on weekends or holidays. I understand that Becky may take vacations and may not have access to emails during those times, but I will be informed of that beforehand.
I understand that all emails may take up to 48 business hours receive a response. I acknowledge this policy and agree to be understanding of that time frame, but in most cases I should receive responses in a more prompt time span. Additionally, I also understand that should anything arise that is so urgent it cannot wait 48 hours, that it is my responsibility as the parent or caregiver to seek medical advice from my child's pediatrician/practitioner or thru an urgent care facility.
I understand when scheduling an appointment that the time will be displayed in Pacific Standard Time (PST), and that it is my responsibility to covert the time appropriately to my time zone/region. I understand that failure to do so may interfere with the schedule and could warrant a cancellation. I will email Becky prior to an appointment if I need clarification on a date or time.
I understand that working with a health coach involves a team effort, but I am ultimately responsible for implementing my child's treatment. I understand that Becky will do her best to advise the best recommendations she sees fit for my child based on their needs with her experience and education. I understand that I will be educated on each recommendation, but there is no way to predict how my child will respond. I understand that there is no guarantee that my child will have a positive outcome, as each child is unique.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: