2024 School Observation Consent Form

2024 School Observation Consent Form

Current SPT Clients
By signing below, I agree and provide my consent for Seattle Play Therapy to provide a behavioral observation for (enter the name of child)* at (enter the name of school/daycare)*.
- I understand that my child will be observed in the classroom setting.
- The day/time/length of the observation will be mutually determined between the school and the provider.
- I understand that it is possible the behaviors I am concerned about may not occur during the observation time allotted.
- I understand that by signing here my provider and my school can mutually exchange information related to my child’s social/emotional and behavioral needs at school.
Financial Information
- Length of the observation is typically 50 minutes at the rate of $255. This includes 25 minutes of verbal feedback with the school.
- To include written feedback, the cost is $425.
- Travel time is billed at $20 per 15-minute increment.
- Any additional services/meetings will be prorated at 15-minute increments at the rate of $170 per hour.
School Contact (Name/Phone/Email)*
School Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Printed Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear

Authorization of Release of Information

I understand that I may authorize that my mental health provider at Seattle Play Therapy to disclose my private health care information to a third party.

I understand that under Washington State law, my mental health provider may charge a reasonable fee for providing my health care information to a third party, and he or she is not required to honor my request or authorization until the fee is paid. I hereby authorize my mental health provider to disclose my private health information as specified below.
The nature of the information to be disclosed is:*

Finances and ScheduleDates of ServiceEntire Treatment RecordsFamily TherapyTreatment SummaryParent SupportSchool-related IssuesOther
Parent(s)' Name(s)*
Contact Information
This authorization of disclosure of my health information will expire when treatment is terminated, unless otherwise indicated below. I understand that if the disclosure is being made to a financial institution or to my employer for purposes other than payment, Washington State law requires this authorization to expire no later than one year after signing. I understand that except as provided by applicable law, my signing of this authorization is not a waiver of any rights I have under other statutes, the rules of evidence, or common law, and that I have the right to revoke this authorization at any time. I understand that my mental health provider will retain the original or a copy of this authorization.
Release of Information Expiration Date
By providing my electronic signature, I am attesting that I have received, read, and fully understand and consent to the disclosures, terms, and conditions above.
Date*

MonthDayYear
Date
Client's Printed Name*
Client Signature*

Clear
Should be Empty: