TLC Day Programs Application

Name*

First NameLast Name

Date of birth*

Date

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

School Name*

Grade*

Parent/Guardian*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Work Number*

Email*

Occupation/Employer

Emergency Contact Information-Alternate Pick-Release

Emergency Contact #1

Name*

First NameLast Name

Mobile Phone Number (Primary)*

Work Phone

Email*

example@example.com

Relation to child*

Emergency Contact #2

Name*

First NameLast Name

Mobile Phone Number (must be different than primary number above)*

Work Phone

Email*

example@example.com

Relation to child*

Please list those people who are permitted to pick up your child*

Your child will not be released to anyone that is not listed above. Please contact us in advance for occasions where an individual not listed will be picking up your child.

Medical Release Information

Insurance information

Name of Health Insurance*

Policy Number*

Primary Physician*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Hospital Preference*

Please list any medical conditions, including any that require maintenance medication (i.e. Diabetes, Asthma, Seizures). If medication needs to be administered while your child is at the program, you will need to come to the program to administer medication. No staff is allowed to administer medication. *

Is your child presently being treated for an injury or illness, or taking any form of medication for any reason? If your answer is yes, please explain:*

Is your child currently receiving therapeutic services? (i.e. occupational therapy, speech therapy, physical therapy, play therapy.) If yes, please explain. *

Does/did your child receive Early Steps services?

YesNo

Can you provide us with contact information and do we have permission to contact Early Steps?

YesNo

If you answered yes to the above questions please provide information here:

Signature

Is your child allergic to any type of food or medication?*

If yes, please explain:

Does your child require one on one assistance at their school, ABA center or daycare?*

If answered YES, please explain:*

The purpose of the below-listed information is to ensure that medical personnel have details of any medical condition which may interfere with or alter treatment.

Does your child have a diagnosis that will assist with program planning? If so, please explain:*

Is your child potty trained?*

If no, please explain current training status:

Does your child require a special diet?*

If yes, please explain:

Please provide us with helpful information if your child becomes upset, such as calm down strategies used at home or school. Also, please share any information that will be helpful for us know in order to better understand your child. (I.e. they may cry when hungry, they crawl under a table when scared, they need hugs for comfort, they need a break from a noisy environment when holding their ears, etc.)*

Please describe to us how your child communicates.*

Please tell us what activities your child enjoys engaging in.*

Does your child react strongly to unexpected or loud noises? (for example sirens, dogs barking, hair dryer) *

Does your child seem to not hear you when you call their name? (even though hearing is ok) *

Is your child bothered by bright lights or prefers bright colors/patterns?*

Does your child display the need to touch people or objects more than peers of the same age? *

Does your child pursue movement to the point where it interferes with daily routines? (for example, can't sit still, fidgets, etc.)*

Does your child put objects in their mouth? (for example, pencil, hands, etc)*

Is your child distressed by changes in plans, routines, or expectations? Please explain.*

When your child needs you to do something for him/her, which of these would they use?*

Can you and your child have a simple back and forth conversation?*

YesNo

How often can your child focus and attend to a task that is non preferred? (For example, some children don't enjoy sitting at a table to draw or when asked to clean up their toys.)*

AlwaysSometimesNever

When your child plays with toys, does he/she use them in a variety of different ways or do they have specific way they play with the toy that is non purposeful? Please explain.*

During play, does your child use words to express emotions or comment on actions/events around them?*

YesNo

What is the main goal or reason for your child to attend one of TLC's day programs?*

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured.

Parent's /Guardian Initials*

Terms of Agreement

The Therapeutic Learning Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded unless a child is unable to participate due to an accident or illness per physician orders.

How did you hear about Therapeutic Learning Center Programs?*

Waiver

THERAPEUTIC LEARNING CENTER, LLC

PARENT

Permission Slip, Waiver of Liability, Indemnification, Medical Agreement

and Grant of Rights

Permission Slip

I, the parent/legal guardian of this participant, hereby confirm that I am allowing my child to participate in the Therapeutic Learning Center, LLC’s (“TLC”) Programs (“Program”). I understand that the Program is completely voluntary and that no academic credit will be given for participation. My signature below is an acknowledgement of voluntary consent to allow my child to participate in this Program.

Waiver of Liability

My signature below indicates my understanding of the details of the Program. On behalf of my child, I voluntarily agree to accept any and all risks associated with their participation in the Program. On behalf of my child, I agree to forever indemnify, hold harmless, waive, and release TLC, its respective officers, members, employees, insurers, and representatives (“TLC Group”) thereof, from liability for any claim which I, any other parent or guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have on my behalf or on behalf of my child, known or unknown, directly or indirectly, for any losses, damages, or injuries, including death, arising from, but not limited to, negligence, omissions, or fault, by or on behalf of TLC.

Indemnification

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 Program.

Medical Agreement

If the participant has any special medical problems, allergies, dietary needs, handicap, special prescriptions, etc., please list (and use additional sheets if necessary) I have explained them in the registration form above.

In case of an emergency, all attempts to reach me should be made to the telephone number(s) stated above on the registration form.

If any emergency medical procedures or treatments are required during the Program, I hereby consent to the staff of TLC’s Program, 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. My signature below also indicates that my child is in adequate physical condition to participate in the Program.

GRANT OF RIGHTS

I, Parent/Legal Guardian, grant TLC the right and license to use my child’s liken, photographs and other attributes (collectively, “Approved Attributes”) to promote and advertise TLC’s services in the media including TV, radio, print advertising, point-of-sale materials, promotional materials, grass roots marketing efforts, public relations efforts and the Internet (to include but not be limited to web banners, blogs and social networking sites).

Declaration

By signing a copy of this agreement, I hereby acknowledge and agree to the above terms, including the PERMISSION SLIP, WAIVER OF LIABILITY, 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.

Severability

The Undersigned expressly agrees that the foregoing Release, Waiver 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.

READ BEFORE SIGNING

Initials*

I give permission for photographs/video of my child to be used for treatment, education, documentation, advertising, brochures, and or webspace:*

Behavior Policy

We recognize that children with behavioral challenges thrive in a therapeutic environment; however, if a child exhibits aggressive behaviors—such as aggression toward other children or staff members—on three or more occasions, they will be asked to leave the program without a refund. In such cases, one-on-one therapy services may be more appropriate to meet your child’s needs.

Support Policy

We acknowledge that some children benefit from individualized support to succeed. If it becomes apparent that your child requires more support than our programs/groups can offer, we reserve the right to transfer them to an alternative TLC program, discontinue their enrollment, or recommend additional services through external providers to ensure their continued success.

Please acknowledge an understanding our behavior/support policy.

Therapeutic Day Programs: Nurturing Growth and Discovery

Welcome to Therapeutic Learning Center! We're excited to embark on a journey of growth, enrichment, and joy with your children. At our center, we believe childhood should be a tapestry of warmth, security, exploration, and discovery.

Our mission is to create a nurturing therapeutic environment that fosters holistic development across social, emotional, physical, and intellectual domains. We achieve this through:

Comprehensive Program Components
Individualized Support: Small client-to-adult ratios ensure personalized attention.

Integrated Therapy: Licensed therapists provide individual and group sessions to address emotional and behavioral challenges.

Skill-Building Groups: Focused activities help children develop coping mechanisms and adaptive behaviors.

Creative Expression: Adjunctive therapies using art, music, and movement enhance self-expression and therapeutic outcomes.

Core Principles
Supportive Milieu: A structured, predictable atmosphere rooted in positive behavioral support.

Social Skills Development: Emphasis on interpersonal growth and positive relationships.

Academic Integration: Customized curriculums allow for continued educational progress within a therapeutic framework.

To ensure your child's success and maintain our commitment to excellence, we have established essential policies. These guidelines are designed to create a safe, respectful, and growth-oriented environment for all participants.

By partnering with us, you're providing your child with an opportunity to thrive in a space that values their unique journey and potential. We look forward to supporting your child's development and witnessing their remarkable progress at Therapeutic Learning Center.

Late Arrival Policy

Therapeutic Day Programs

Please be aware that all children attending our day programs must be picked up by 2:25 pm, as we have afternoon outpatient appointments starting promptly afterward. If you arrive after 2:30 pm, a $25 late fee will apply. For pickups after 2:30 pm, an additional fee of $1 per minute will be charged for each minute late. If late pickups exceed three occurrences, we reserve the right to remove your child from the program. We appreciate your understanding and cooperation.

Afternoon (Social Groups) Programs

Lead therapists offer feedback during the final five minutes of the group session. To ensure you receive individual feedback, please arrive for pick up on time (at least 10 minutes prior to the session ends), as late arrivals will not be accommodated for feedback.

Illness Policy

For the health and well-being of all children, please do not send your child to TLC if they are sick. Children who arrive at TLC visibly ill, with a rash, pink eye, excessive coughing, vomiting, diarrhea, or a fever will not be permitted to attend.

Children may return once they have been symptom-free for at least 24 hours, including:

Fever
Vomiting
Diarrhea
Contagious rash
If a child develops any of the following symptoms during the day, a parent or guardian will be notified immediately and asked to pick up the child:

A fever of 100.4°F or higher
Vomiting
Diarrhea
If your child is sick at home and cannot attend, please notify us as soon as possible by emailing programs@tlcnola.com, sending a message via the Brightwheel app, or calling our office at 504-565-7300. Please note that refunds are not provided for illnesses.

Absences/Vacation Policy

Refunds or credit will not be provided for unexpected or planned absences, early pick-ups, or late arrivals. This includes, but is not limited to, sick days, vacation days, or instances where your child leaves early or arrives late due to personal commitments or prior appointments, as we continue to reserve the spot for your child.

Holiday and Weather Closure Policies

Holiday Closures:
TLC will be closed in observance of the following holidays: New Year's Day, Mardi Gras Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the Friday after Thanksgiving, and Christmas Day.

If a therapist needs to cancel a group session, you will receive a credit for that session on your invoice for the following month.

Weather Closures:
Refunds will not be issued in the event of an unexpected closure of TLC due to inclement weather.

Consultation Fee Policy

If your child requires a consultation between TLC staff and school teachers or other professionals, a consultation fee of $20 per 15 minutes will apply. This service will only be available after your child has attended at least 4 group sessions.

Trial Policy

At TLC, our primary goal is to create a fun and supportive environment where all children can succeed; however, there may be times when our student-to-staff ratio does not allow us to provide the individualized support (one-on-one) necessary to maintain safety and regulation throughout the group or day program.

Afternoon Social Skills Group

Upon entering the Social Skills Group, each child will begin with a trial session. This allows our therapist to assess whether the group can meet your child’s specific support needs. After the trial session, the therapist will provide feedback on whether the group is suitable to meet your child’s current needs and goals.

If it is determined that the group cannot provide the required level of support, we will recommend alternative options. These may include:

Discontinuing the group while seeking additional support, such as adding a mental health professional to your child’s care team or seeking individual services.
Requiring a shadow to provide one-on-one support for your child throughout the day.
Building Blocks Therapeutic Day Program

Upon enrollment, each child will begin a 15-day trial period. This allows our therapists to assess whether our program can meet the specific support needs necessary for your child’s success. At the end of the trial period, the therapist will provide feedback on whether the program aligns with your child’s current needs and goals.

If it is determined that the program cannot offer the required level of support, we will recommend alternative options. These may include:

Reducing attendance to half days until your child can manage a full day,
Temporarily discontinuing the program to explore additional support, such as adding a mental health professional to your child’s care team or focusing on individual speech and/or occupational therapy services.
Requiring a shadow to provide one-on-one support throughout the day.

Enrollment and Tuition Policy

Afternoon (Social Groups) Programs
Starting March 1st, 2025, your child will be continuously enrolled in our program, and you will receive a monthly invoice based on your child’s group enrollment as of one week prior to each month. The monthly tuition for all Afternoon Groups (Lego Group, Handwriting Group, and Social Skills) is $150.

Once enrolled, your child’s admission is continuous, and you will not need to re-register each month. To discontinue services, please email TLC at programs@tlcnola.com. If you are unsure about your child’s timeframe in the program, the lead SLP or OT will communicate with you when your child is ready to graduate.

Notice for Discontinuation
To discontinue enrollment, a written notice must be submitted at least two weeks in advance to programs@tlcnola.com, even if you have informed the lead therapist verbally. No refunds will be issued if proper notice is not provided. Failure to give two weeks’ notice will result in responsibility for one week’s tuition beyond the dismissal date.

Invoices and Payment
Tuition is invoiced electronically through Brightwheel, and invoices will be sent to your email on file one week before the month your child will attend, or sooner if early availability allows for immediate billing. Invoices are due on the last day of eachmonth and must be paid electronically via the Brightwheel platform. Please check your spam folder for invoices and ensure that “support@mybrightwheel.com” is marked as a trusted contact in your email settings.

If payment is not received by the last day of the month, a $25 late fee will be charged. If payment is not made by the 1st of the month, a credit card will be required to be kept on file, and your card will be charged the late fee. Failure to provide a credit card may result in your child’s spot being placed on hold and moved to the waitlist.

To avoid late fees, we recommend using the "autopay" feature on Brightwheel, which will automatically charge your card on the due date. For any questions, please contact our office or email programs@tlcnola.com.

Building Blocks Therapeutic Day Programs
Once enrolled, your child’s admission is considered continuous, and there is no need to re-register each month. To discontinue services, email TLC at programs@tlcnola.com. If you are unsure of your child's timeframe, the lead therapists will let you know when your child is ready to graduate from the program.

Invoices and Payment
Tuition for Building Blocks Therapeutic Day Programs is invoiced through Brightwheel, and the invoice will be sent to your email on file. Tuition is due on the last day of each month and is based on the number of scheduled days your child will attend that month, depending on whether you selected the 2-day, 3-day, or 4-day option. Payment must be made electronically via the Brightwheel platform. Be sure to check your spam folder and mark “support@mybrightwheel.com” as a trusted contact to ensure you receive the invoice.

Invoices will be sent one week before the month your child will attend unless there is early availability for immediate billing. If payment is not received by the last day of the month, a $25 late fee will apply. If payment is not made by the 1st of the month, a credit card will be required to be kept on file, and your card will be charged the late fee. Failure to provide a credit card will result in your child’s spot being placed on hold and moved to the waitlist.

To avoid late fees, we encourage you to use the "autopay" feature on Brightwheel, which automatically charges your card on the due date. For any questions, please call our office or email programs@tlcnola.com.

Seasonal Therapeutic Day Programs (Fall, Winter, Mardi Gras, etc)

Tuition for the Seasonal Therapeutic Day Programs will be invoiced through Brightwheel, and the invoice will be sent to the email address we have on file. You have the option to pay the tuition in full or in two installments. A payment due date will be set according to the start date of each program. All payments must be made electronically via the Brightwheel platform by the due date. Please note that if enrollment is canceled after the tuition due date, no refunds or credits will be issued. Keep an eye out for an invitation and invoice from Brightwheel, and feel free to reach out to programs@tlcnola.com with any questions. We look forward to working with your children!

Emergency Policy

In the event of a personal emergency, please contact the office at 504-565-7300 to inform us of alternate arrangements for picking up your child.

If a weather-related event occurs that requires your child to be picked up, we will reach out to you and ask that you either pick up your child immediately or arrange for a designated person to do so. Please note that no refunds will be issued for closures due to weather events.

Additionally, please notify TLC via email at programs@tlcnola.com or by calling 504-565-7300 if:

Someone other than the usual pick-up person will be collecting your child.
Your child will only be released to individuals listed on your pick-up authorization form, and they will be asked to present identification if we are not familiar with them.

Separated or Divorced Parents Policy

Our Commitment to Collaborative Care

At Therapeutic Learning Center, the best outcomes for children are achieved when parents work together with our therapists. This policy fosters a collaborative environment where parents, regardless of marital status, actively participate in their child's therapeutic journey.

Joint Communication Approach

Primary Communication Method: We will utilize a single, shared communication channel for both parents. This ensures that all information is delivered simultaneously and consistently to both parties.

Joint Parent Portal: Parents will be provided access to a secure online portal, “Brightwheel”, to view updates, progress reports, and upcoming activities together.
Unified Email Communications: If requested, all email correspondence will be sent to both parents simultaneously, promoting transparency and equal access to information.

Session Feedback and Attendance

Immediate Feedback: Feedback on the child's progress and session details will only be provided to the parent who brings the child to the session or attends the session, either during or directly following the session.

Attendance for Feedback: If a parent wishes to receive immediate, detailed feedback about a specific session, they must attend in person.

Equal Opportunity: Both parents are strongly encouraged to attend sessions regularly to receive firsthand information and participate actively in their child's therapy.
If a parent cannot attend, the parent can schedule a separate appointment with the therapist for a consultation. We have a separate fee for this service.

Expectations for Parental Cooperation

Shared Responsibility: We expect both parents to actively participate in their child's therapy process, sharing responsibility for communication, decision-making, and meeting attendance.

Joint Attendance: Whenever possible, both parents should attend therapy sessions, progress meetings, and other important events together.

Unified Decision-Making: Parents are encouraged to discuss and agree on therapeutic decisions before communicating with therapists, presenting a united front in their child's care.

Therapist's Role in Facilitating Cooperation

Neutral Facilitation: Our therapists will act as neutral facilitators, encouraging both parents to work together in the best interest of their child.

Equal Opportunity: Therapists will ensure that both parents have equal opportunities to contribute to discussions and decision-making processes.

Commitment to Child's Well-being

Focus on the Child: All interactions, decisions, and communications should prioritize the child's well-being and therapeutic progress.

Positive Co-Parenting: Parents are encouraged to model positive co-parenting behaviors, demonstrating unity in supporting their child's therapy.

By adhering to this policy, you agree to work collaboratively with each other and our therapists, creating a supportive and consistent environment for your child's growth and development. This unified approach will significantly enhance the effectiveness of our therapeutic services, and programs and ultimately benefit your child.

Graduation or Discharge from Group/Day Program Policies

In the event that your child graduates from the program or group in the middle of the month, you will receive a refund for the remainder of days in which your child was scheduled to attend. Official graduation will be determined during a parent meeting with the lead therapists in which all agree that your child has met the established goals and no longer requires the program or group. We will not determine that a child is ready to graduate, unexpectedly, without alerting parents in advance to ensure that a transition plan is in place.

Refunds will not be issued for unexpected discharge or discontinuation of the programs or social skills group for any of the following reasons:

Child behavior that is beyond our ability to control, which is harmful to others or themselves. No tuition or fees will be reimbursed.
In the event that your child shows aggressive behavior for 3 incidents, we will recommend a psychological evaluation. Following this evaluation, we will collaborate with the psychologist to discuss continued enrollment in the program and to ensure the safety and success of all of our children.
Parental decision to pull from the program without warning (see below).
Late pick up on more than 3 occasions.
Noncompliance with payment or other site policies and procedures.
Please note, we require a two weeks advance notice sent to programs@tlcnola.com if you plan to leave the program for any reason.

Written notice of program discontinuation is required to programs@tlcnola.com, even if you tell the lead therapist. No refunds will be provided if two week's notice is not provided in writing. You will owe one week’s tuition past the date of notice.

Please acknowledge an understanding our policies. *

Printed Name of Parent/Guardian*

Date*

Date

PLEASE INITIAL BELOW: (1) I understand that my child will need to attend a trial day to determine if he/she can be supported by TLC Day Programs. (2) If my child is not able to be adequately supported by TLC Day programs, there will be alternate recommendations for providers that can be helpful. (3) I understand that Brightwheel will be the program used to send invoices and receive payments for my child. (4) I understand that I am required to submit a credit card on file to be used if my invoices are overdue. (5) I understand that due to the nature of this program being therapeutic, my child's placement will be determined by the Programs Director.*