CLIENT POLICIES AND CONSENT
Revised February 2023 -MD
Welcome to our occupational therapy program at Step-by- Step Pediatric Therapy, Inc. Our team of outstanding therapists are committed and dedicated in assisting you and your child’s developmental needs and education. We look forward to working with you and your child and creating a professional and caring relationship. Your participation in our program is vital---you are an integral part of the team! Together we will make a difference! In order to serve you and your child effectively under a mutual understanding of our guidelines, please carefully read the following policies and sign at the bottom of the page.
PRIOR TO SERVICES
- All forms must be submitted online. If you do not have access to a computer, your information will be taken and inputted by one of our office staff members.
- Unless paying privately, authorizations must be in place prior to receiving services.
- If using insurance, it is recommended that you check with the insurance company to ensure that the requested services are a covered benefit per your policy. The SBSPT front office will also contact the insurance company once you have provided your information. If the front office indicates that a prescription is required, you must obtain this from your child's doctor and provide it to the front office prior to the appointment.
CONDITIONS OF TREATMENT
1. CONSENT TO TREATMENT/ASSESSMENT
I hereby consent to the administration and performance of all evaluation procedures and treatments within the realm of current standards of practice, which in the judgment of my child’s therapist may be considered necessary or advisable.
2. CONSENT TO TELEHEALTH TREATMENT
SBSPT may recommend services through telehealth if clinically appropriate. I understand that my child will be receiving care through interactive audio, video, and other telecommunication technologies with a therapist who is not in the same physical location as me and my child. I understand that I am expected to provide a safe environment with minimized distractions for my child to participate in telehealth treatment. There is a risk of technology failure and interruption by a connectivity problem. I will need access to, and familiarity with, the appropriate, working technology for my child and me to participate in the services provided by SBSPT, with a risk of technology interruptions. I also agree that my child and I are responsible for timely attendance, and that I remain responsible for adhering to SBSPT’s “Third-Party Funders,” “Parent Presence,” and “Attendance” policies.
3. CONSENT TO USE OF THERAPEUTIC EQUIPMENT
I, on my behalf and on behalf of my child, fully understand that there is a risk of personal injury to my child in participating in play-based activities and other physically active games through the programs provided by SBSPT. I am aware that my child is engaging in physically active games and/or therapeutic activities, which could result in injury. I am voluntarily allowing my child to participate in these activities and assume all risks of injury that may result. I personally, and on behalf of my child, agree to hold no individual or corporation responsible or liable for any injuries and associated costs that my child receives on account of these activities, including but not limited to SBSPT, or it’s officers, employees, agents, aides, therapists, assistants, successors, instructors, interns, insurers, or assigns (hereinafter “Releases”). I further agree to waive any claims or causes of action against and to hold harmless said Releases for any injuries or damages which my child suffers or might suffer as a result of the conduct of any person during or in conjunction with said physically active games or therapeutic play-based activities.
4. CONSENT TO PHOTOGRAPHY
I hereby agree to allow SBSPT to take and/or use any pictures/tapes/videos/films of me or my child with my full knowledge and consent as a client of SBSPT. This visual record may be used for teaching and training activities and/or as a part of my child’s medical/developmental record as SBSPT may deem proper. My child’s identity will not be made public without my expressed permission for a specific occasion or purpose. Any use of my child for public relations will also require my specific permission and knowledge.
5. CONSENT FOR EMERGENCY TREATMENT
As the authorized representative, I hereby give consent for SBSPT, to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D), osteopath (D.O.), or dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child. My signature at the bottom of this form testifies that I am the authorized representative of the child named on this document. Further, I will be responsible for the charges for any medical or dental treatment or hospitalization rendered by reason of this authorization.
I understand that in order to attend in person services, households must follow current CDC quarantine/isolation guidelines in case of a COVID-19 exposure or diagnosis (suspected or confirmed). I understand that if a child (or someone in the child’s home) experiences any symptoms of illness, the child should participate in telehealth until all symptoms (including, but not limited to, fever, vomiting, diarrhea, nasal congestion, cough, sore throat, skin irritation) have been fully resolved for at least 24 hours without medication. In the event that mild symptoms persist for more than 5 days, children may be allowed to return in person after presenting a doctor’s note indicating they are not contagious and/or a negative COVID-19 test. I understand that if a child shows symptoms of illness while receiving in person services, SBSPT staff will separate them from peers and contact caregivers for immediate pick up.
7. RELEASE OF INFORMATION
I hereby agree that SBSPT may release information, either written or verbal, regarding my child’s medical status and progress to professionals who have been or are currently involved in the treatment of my child. I hereby agree that, to the extent necessary to determine eligibility for services and to obtain reimbursement, SBSPT may disclose portions of my child’s records to funding agencies such as health care insurance plans, school districts, and regional centers.
8. ATTENDANCE POLICY
It is extremely important to consistently attend appointments on time and avoid unnecessary cancellations. I hereby understand and agree to ASAP’s Attendance Policy.
- 24 HOUR ADVANCE CANCELLATIONS:
- Therapist/teacher will schedule a make up session as soon as the cancellation has been reported. If there’s a schedule conflict, the admin will call on the same day to schedule with another therapist or with a supervisor.
- Makeup is mandatory after 2 excusable absences to ensure integrity of the program. Parents must be open for teletherapy make-up with a supervisor or other therapist. *A make up with a supervisor will be used to assess program quality including client’s treatment plan.
- Excessive acceptable cancellations (ie. chronic illness) will be offered week by week appointments instead of a permanent schedule or decrease frequency. Therapists will vary each week based on who is open.
- NO SHOW/LAST MINUTE CANCELLATIONS (NSLMC): Sessions are considered a "no show" if I have not communicated with ASAP within the first 15 minutes of the session. No shows can result in my child’s therapy being terminated.
- Admin will call and discuss attendance policy and determine if services are warrant or if scheduling is an issue.
- Makeup is mandatory for every no show to ensure integrity of the program. Parents must be open for teletherapy make-up session with a supervisor or other therapist. *A make up with a supervisor will be used to assess program quality including client’s treatment plan.
- No Show is considered an unacceptable absence. Clients with 3 no shows will be immediately returned to the referring agency/source.
- First NSLMC: The administrator or teacher will provide a reminder.
- Second NSLMC: The referring agency will be notified of poor attendance.
- Third NSLMC: Services will be terminated.
- LAST MINUTE CANCELLATIONS (WITHIN 2 HOURS): Sessions are considered “last minute cancellation” if I do not cancel within 2 hours of the appointment. Last minute cancellations can result in my child's therapist being terminated.
- Therapist/teacher will schedule a make up session as soon as the cancellation is reported. If there’s a schedule conflict, the admin will call on the same day to schedule with another therapist or with a supervisor.
- Makeup is mandatory for every last minute cancellation to ensure integrity of the program. Parents must be open for teletherapy make-up session with a supervisor or other therapist. *A make up with a supervisor will be used to assess program quality including client’s treatment plan.
- After 2 last minute cancellations, each subsequent last minute cancellation will be treated as a “no show” and will follow “ No Shows” regulations.
- MULTIPLE CANCELLATIONS: All subsequent cancellations after two cancellations within a 6-month authorization period must be made up if the clinic has availability for make up.
- TARDINESS: You and your child are expected to be on time and ready for your child’s session. In the event that you are running late, you must notify the office and/or teacher. It will be in the therapist’s discretion to cancel or continue the session. Going over the scheduled time to make up for the missed time due to tardiness is not allowed.
- THERAPIST CANCELLATIONS: In the event that a session is canceled due to the therapist being ill or for personal reasons, a make up session will be offered if available. Make up sessions are not guaranteed to be completed by your child’s regular teacher. Sessions that are missed due to the teacher's vacation and/or continuing education are not guaranteed to be made up as teacher are mandated to take continuing education to keep current with the latest interventions. In addition, teacher are also entitled to vacations during the year. However, every effort to provide make up sessions will be made.
- THERAPIST TARDINESS: In the event the teacher foresees being over 15 minutes late, the teacher will call to notify you of their tardiness and expected time of arrival. It will be your discretion to cancel or continue the session. Additional time will be allotted to equal the missed portion due to the therapist’s tardiness.
- HOLIDAYS: Every effort to provide make up sessions for holidays will be made but not guaranteed.
- VACATIONS AND PROLONGED ABSENCES (SURGERY/RECOVERY; VACATION; SCHEDULING ISSUES; ETC.):
- Client’s will be placed in a “hold” if they are not able to return to their regular scheduled appointments after 2 weeks.
- A new time slot will be offered once the client returns. Having the same therapist is not guaranteed but will be a priority.
- OTHER: All cancellations must be made up according to what is allowed and permitted by the referring agency. Make up sessions are not guaranteed to be with your regular teacher. Make up sessions will be offered via teletherapy if in person scheduling is not available.
9. FINANCIAL AGREEMENT (insurance and private clients only)
- I understand that payments are due at the time of service.
- I understand that last minute cancellation or no-show fees of $75.00 are due at the time of my next scheduled session.
- I understand how insurance verification and billing works (whether I am in-network or out-of-network).
- I authorize the release of all medical records to referring therapists and my insurance company.
- It is my responsibility to notify the front office at SBSPT if there are changes to my child’s insurance. In the event that my insurance or other funding agency does not pay within 90 days for rendered services, regardless of the reason, I am responsible for payment.
10. PARENT PRESENCE AND PARTICIPATION
Therapy sessions are provided individually or in group settings depending on the service/clinical recommendation. If my child is receiving therapy in a home or community, a caregiver must be present at all times. If my child is receiving therapy in the clinic, caregivers may remain in the waiting room or participate in the session as long as they are directly with their child and therapist. I understand that observing from afar, using cell phones, reading, or using a computer is not permitted within the clinic treatment space. Parent participation is always encouraged.
11. SIBLINGS AND ACCOMPANYING CHILDREN
I understand that caregivers are responsible for supervising all children brought to the SBSPT waiting room, and that only children under direct care of a SBSPT therapist may use equipment and toys in the treatment space.
12. DROP-OFF AND PICKUP
I understand that children must be monitored in the waiting room and cannot be dropped off unattended. If I or another caregiver is leaving the clinic, I/he/she/they must provide a phone number at the front desk in case of an illness or emergency. I understand that caregivers are expected to arrive at the clinic 5 minutes prior to the session ending for a prompt pick up. There is a flat fee of $10 plus $2/minute late fee for pickups after the end of a session.
SBSPT does not follow any restrictive approach towards a child’s negative or aggressive behavior. SBSPT does not use restraints, force, yell or scream to stop a child’s negative or aggressive behavior. SBSPT uses a re-direction and sensory calming approach. In the event that these strategies do not work, it is expected that parents assist in managing the child’s behavior. For this reason, it is imperative that parents stay in close proximity to their child and do not leave the premises while the child is in therapy. I understand that SBSPT does not use restraints and or any forms of restrictive approach towards a child’s negative or aggressive behavior.
14. EMERGENCY CONTACTS
I understand that SBSPT may contact or release my child to emergency contacts I list on this form if a primary guardian is not available at the end of a session or program, or in the case of an emergency.
15. EMERGENCY EVENT
Following an emergency event, assuming conditions are deemed safe, children will be released to their guardians. If it is not feasible for a guardian to pick up a child, employees will take children to a verified safe location determined by the American Red Cross and/or communicated by the National Emergency Broadcast System.
Yearly evaluations are conducted for private pay clients per standard best practice guidelines. Evaluations for services through a funding agency are conducted according to the agency’s guidelines.
At times, therapists will take time for meetings, continuing education, vacation, or sick time. When this impacts scheduled appointments, SBSPT will provide coverage whenever possible.
18. INTERNSHIP PROGRAM
SBSPT collaborates with accredited universities throughout the country by accepting occupational therapy interns as part of fieldwork/internship programs. I understand that when my child’s therapist is a clinical instructor, it is likely that an intern will participate in all aspects of my child’s treatment with supervision from their clinical instructor(s).
19. VOLUNTEER/NEW HIRES OBSERVATION CONSENT
I give permission for volunteers or prospective employees to observe my child’s occupational therapy sessions.
20. TELETHERAPY/IN PERSON
I understand that I have the right to switch between in person service to teletherapy service at any given time and vice versa. However, I will need to give my therapist a minimum of 2 week notice to allow for proper scheduling. In addition, I understand that by choosing in person services, you, your child, and the rest of the family have a chance of possible exposure to COVID. I do not hold Step-By-Step Pediatric Therapy, Inc. and Clubhouse or staff at fault in case there is exposure to COVID.
21. TRANSLATION SERVICES
I understand that translation services are available for certain languages (all language available for Kaiser and ESSC clients) and that I give permission for translation as needed. However, translators may or may not be certified.
22. TREATMENT SESSION BREAKDOWN
- TELETHERAPY SESSION: Total 60 minutes broken down as follows
- 50 minutes: Tech set up/contact parents, direct therapy/session. Sessions to address goals, treatment plan, and parent education/question and answers.
- 10 minutes: Therapist to write daily treatment notes and plan for the next session. (completed outside the session)
- IN PERSON: Total 60 minutes broken down as follows
- 50 minutes: COVID screening process including handwashing, direct therapy, and parent training. Sessions to address goals, treatment plan, and parent education. Client check out/signatures obtained and answer any parent questions.
- 10 minutes: Therapist to write daily treatment notes and plan for the next session. (completed outside the session)
- END OF SESSIONS
I understand that discussions with caregivers about activities and goal progress are part of intervention. Therapists and children may arrive in the waiting room prior to the session ending to account for this if parents are not present during the session.
SBSPT strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability. I understand that I and other guardians of my child are expected to participate in this endeavor and show mutual respect for members of our community.
24. YOU AND YOUR CHILD’S HAVE RIGHTS
You understand that you and your child have the right…
- To be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
- To a prompt and reasonable response to questions and requests.
- To know who is providing medical services and who is responsible for his or her care.
- To participate in the development and implementation of the patient plan of care.
- To know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
- To know what rules and regulations apply to his or her conduct.
- To be given by the healthcare provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
- To refuse any treatment, except as otherwise provided by law.
- To be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
- To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
- To receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
- To impartial access to medical treatment or accommodations, regardless of race, national origin,religion, handicap, or source of payment.
- To treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
- To express grievances regarding any violation of his or her rights, through the grievance procedure of the healthcare provider or healthcare facility which served him or her and to the appropriate state licensing agency.
25. A PATIENT/FAMILY/GUARDIAN IS RESPONSIBLE FOR
You understand that you have the responsibility to..
- Providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
- Reporting unexpected changes in his or her condition to the health care provider.
- Reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
- Following the treatment plan recommended by the health care provider.
- Keeping appointments and, when he or she is unable to do so for any reason, notifying the health care provider or healthcare facility.
- His or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
- Assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
- Following health care facility rules and regulations affecting patient care and conduct.
- Active participant during your child’s therapy session
Clients that wish to file an internal grievance against the program must follow the following procedures. The following procedure will help the company address the client’s problems and/or concerns.
A. Dealing with Grievances Informally
- Clients are encouraged to talk to the office manager first in an attempt to resolve matters. This is a way to resolve problems quickly and easily.
- The clients shall call the main office and request to talk or meet with the office manager. A face-to-face meeting and/or a phone call must be completed within 5 days from the request.
- If the grievance does not get resolved through the informal process, the client will be advised to go through the formal grievance procedure.
- There are limits to the informal option. It is unlikely to be suitable for dealing with a very serious incident, as it will not involve a formal investigation. In situations where a more in- depth investigation and a disciplinary outcome may be needed, then the formal procedure would be more suitable.
B. Dealing with Grievances Formally
The formal procedure consists of the following step:
- Starting the Process: Complete a Grievance Form and send to Anna Holley, Program Director.
- Meeting: A formal meeting with the program director will be scheduled within 5 business days from the time the letter of complaint is received. Additional meetings may be held to meet with witnesses and other parties involved. All witnesses who give information will do so privately and not in the presence of anyone else who was involved in, or who was present during, the events giving rise to the grievance. All information or evidence provided by witnesses will be treated as confidential.
- Investigation: The program director will carry-out any further investigations that are necessary and will keep detailed and accurate records of all meetings.
- Decision: Having obtained all relevant information, the program director will consider whether the facts support the grievance and, if so, what disciplinary action, if any, needs to be taken, or whether other action is warranted. The manager will prepare a written report of the investigation and its findings. Within 10 working/business days, the client will be informed about the outcome of the investigation. This will be done in a meeting, if possible, and will be confirmed in writing.
- If the client is in disagreement with the final outcome, the referral/funding source service coordinator will be notified.
27. ADDITIONAL INFORMATION
- We expect your child to be awake and full during visits. Feed your child 30 minutes before the scheduled session and allow your child to nap prior to his/her session. *Unless it is feeding therapy, then discuss appropriate time for therapy with your therapist.
- Always sign the attendance sheet at the end of each session.
- Step-by-Step Pediatric Therapy, Inc. is required by California State Law to report any case of suspected child abuse.
STEP-BY-STEP PEDIATRIC THERAPY, INC.
15454 Gale Avenue, Suite F
Hacienda Heights, CA 91745
18800 Amar Road Suite B14
Walnut, CA 91789
Phone: (626) 269-3040
Admin Email: firstname.lastname@example.org
Fax: (626) 239-1868