Bear Care: Thrive Time OT Program

Support
Is your child receiving outside occupational therpy or any other services (e.g., physical therapy, speech therapy, etc)? Please write-in details.
Is your child on an IEP, IHP, 504 plan or any other school plans?

Other
Please describe your child's individualized plan.
Child's Information
Please write-in what concerns you have about your child. Include social skills, emotional skills, or mental health well-being. Feel welcome to include observations made by other family members, friends, or teachers.
Is there anything else you want us to know about your child?

Consent for Health Services

By signing this form, I agree that I understand the following information:

Thrive Time at Bear Care Clinic is designed to support children’s growth and skill development through occupational therapy. Following the completion of the program, our team may provide further recommendations for services, strategies, or referrals to help your child continue to progress. Please note that occupational therapy is not an exact science, and every child responds differently to intervention. While our therapists use evidence-based practices and individualized plans, specific results cannot be guaranteed.
- I authorize Rise Up Health Clinics (which operates the Bear Care Clinic to provide occupational therapy services through the Thrive Time program.
- I have the right to refuse or discontinue programming at any time.
- If I have any questions about the services provided, I will ask the healthcare provider.
- I consent to receive communications from the clinic, including appointment reminders and follow-up calls.
- Rise Up Health Clinics may use student health records to evaluate the quality of care and program effectiveness.
Patient Information

The Notice of Privacy Practices and the Patients’ Rights and Responsibilities have been made available to me via the link in this statement and on the clinic website.

https://www.riseuphealthclinics.org/patientinformation
By checking the box below, I acknowledge I have received access to the Notice of Privacy Practices and Patients' Rights and Responsibilities.
By signing my name below, I consent to all the above information in this form.
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