Session Availability/Please select all days and times that may work. 

Right to Revoke Authorization

I understand that I may revoke this authorization at any time by providing written notice to Lighthouse Therapy Center. I understand that revocation will not apply to information already disclosed or actions already taken in reliance on this authorization.

Voluntary Authorization

I understand that signing this authorization is voluntary and that my child’s treatment, payment, enrollment, or eligibility for benefits will not generally be conditioned upon signing this authorization, except as permitted by law.

Expiration of Authorization

This authorization will remain in effect while my child is receiving services from Lighthouse Therapy Center and will expire upon discharge from services, unless I revoke it earlier in writing.

Attendance & Consistency

Therapy is an ongoing scheduled service. I understand that consistent attendance is important for my child’s progress and that repeated failure to attend scheduled visits may result in removal from the ongoing therapy schedule.

24-Hour Cancellation Policy

I understand that Lighthouse Therapy Center requires at least 24 hours’ notice when canceling a scheduled therapy appointment.

Missed Appointments

I understand that after 3 missed appointments without proper 24-hour notice, my child may be removed from the ongoing therapy schedule.

Parent/Guardian Presence

I understand that I, or another authorized adult, must remain on the premises while my child is receiving services unless other arrangements have been approved by Lighthouse Therapy Center.

Late Pick-Up / Waiting for Parent

I understand that repeated instances of the therapist having to wait for me or an authorized adult to pick up my child may affect my child’s ability to remain on the ongoing therapy schedule.

Authorized Pick-Up

If someone other than the parent/legal guardian listed on the intake form will bring or pick up my child, I understand that Lighthouse Therapy Center may require prior authorization and photo identification.

Daycare & Spanish-Language Services

I understand that daycare-based services within the clinic’s service area and Spanish-language services are offered based on provider availability and are not guaranteed.