I am aware that gross motor activities are often encouraged during therapy and that swinging, running, climbing, jumping and other gross motor activities can be used to assist with a variety of skills and performance components the therapist may need to address. I consent to the use of gross motor activities as part of the process. I acknowledge that participation in these activities involves a level of physical risk, and I agree to Cobb Speech and Language Services and its employees and clinicians harmless for injuries that occur.

I understand that therapy sessions may take place outside of the clinic, including but not limited to daycare, preschool, ABA Centers or other community settings, where the presence of non-therapeutic individuals such as family members, caregivers, or staff may be present. I acknowledge that these environments may introduce additional risks or hazards outside the control of Cobb Speech and Language Services. I agree that Cobb Speech and Language Services are not responsible for any accident, injury or harm that occurs during therapy sessions in non-clinical settings, including but not limited to accidents caused by environmental factors, other individuals, or circumstances unrelated to the clinician's direct control.

I authorize the named patient to participate in therapy sessions conducted in natural environments including daycare, preschool, ABA Centers, and other community settings, as determined appropriate by the clinician. I understand that these settings may involve the presence of other individuals such as children, siblings, parents, teachers, and supervised professionals, including interns or students-in-training. I acknowledge that privacy may be limited in these environments, and I consent to the reasonable disclosure of therapy-related information to relevant individuals involved in the patient's educational or caregiving setting (e.g., teachers, aides, or administrators) when necessary to support therapy goals and carryover. I understand that such information will only be shared in accordance with applicable privacy laws, including HIPAA and FERPA.

I give representatives from this facility permission to record and/or photograph my child during any speech or occupational therapy or evaluation session. I am aware that this information may be used for caregiver education and may be used for advertising business purposes (including flyers, brochures, videos, social media, websites, etc.) and other forms of marketing and/or employee training. I acknowledge that providing this permission is OPTIONAL, and my child's therapy or evaluation will not be affected by my decision. I am also aware that I can retract this permission at any time by informing the facility in writing. I am aware that I can OBJECT to having my child part of advertising for the facility.

I agree that any and all legal claims arising against Cobb Speech and Language Services, its therapists, employees, owner, or affiliated companies will be resolved through binding arbitration in accordance with the rules of the American Arbitration Association and governed by the laws of the State of Georgia. I understand that arbitration is a final and binding resolution, and I agree to pay the costs of arbitration unless otherwise determined by the arbitrator. I further agree that in the event my claims are unsuccessful, I will pay the arbitration fees and a portion of the attorney's fees for Cobb Speech and Language Services.

In the event of a medical emergency during therapy, I grant permission to seek immediate emergency care for the patient from a hospital, physician, or other healthcare provider as necessary. I understand that this consent applies to life-threatening situations or when the patient's health or safety is at risk. I also acknowledge that Cobb Speech and Language Services, will make reasonable efforts to notify me or the designated emergency contact as soon as possible following any such incident. I understand that I am responsible for any costs associated with emergency care provided by third-party healthcare providers.

I consent to Cobb Speech and Language Services, communicating with me or any other guardian listed in this document by email, phone, or text. I understand that these communications may include appointment reminders, insurance-related matters, payment reminders, and clinical care-related information. I acknowledge that Cobb Speech and Language Services, may leave messages on voice-mail, via text, or email regarding these matters. This consent is valid from the date signed until treatment is terminated, and I understand that I may withdraw my consent in writing at any time. Withdrawal of consent will not affect any treatments or services already provided, but it may impact how future communications are made with me or on my behalf.

I have read and understand the policies above, and I agree to the terms as stated.