Consent & Waiver
You voluntarily desire to participate in the services provided by Illuminate Family Workshop (the “Practitioner”). In exchange for participation in these services and/or use of the property, facilities, and services, you consent to the following:
1. About Me: Treisha Wan, M.A. CCC-SLP
As the Practitioner, I am holding myself out and practicing as a speech-language pathologist. My highest educational degree is a Master of Arts in Speech-Language Pathology and I am licensed to provide services in my field with the state of Arizona. If you have any questions about my education, training or experience before you start receiving my services, please do not hesitate to ask.
2. Services
My Services include the following:
- Getting Acquainted Consultation during which you and I will make an initial determination about whether or not we believe my services are a good fit for you.
- After that, I may recommend, and you may choose to receive, any of my Services or Follow Up appointments, depending on my assessment of your needs.
- My Services may consist of a speech/language screening, comprehensive speech-language evaluation, personalized recommendations, reports, individual therapy service package, group therapy services, parent coaching, and consultation with related services.
Throughout our work together and the delivery of the Services, I will offer a variety of professional recommendations that will likely include facilitation of hierarchy of prompts to achieve target sounds/language skills, generalization of skills, encouragement of new insights, and experimentation with new behaviors/habits. Change usually involves letting go of things that are familiar in order to make room for new possibilities to emerge. Also, changes that you make in one area of your life may induce changes in other areas. All in all, you understand that there are no guarantees of what you will experience, the results you will achieve, or how you will feel during and after working together.
3. Voluntary Participation & Informed Consent
The Consultations, Services and Training that the child may receive have both benefits and risks, and it is important that you are aware of both the benefits and the risks. For instance, application of recommendations may result in improvement in speech sound intelligibility, phonemic awareness, vocabulary knowledge, sentence structure, narrative structure, executive function skills, and comprehension of verbal and written language. It may result in changes in positive self-image, confidence, deeper familial connections, greater happiness, etc. At the same time, since our work together often involves collecting data on areas of speech-language-cognition that highlight challenges for a child (potentially during a comprehensive evaluation), encouraging challenging tasks (potentially during therapy) as well as discussions around medical/social history and areas your family is currently struggling with, you and the child may experience uncomfortable feelings like sadness, guilt, anger, frustration, and/or helplessness in the process.
You acknowledge that you are choosing to participate voluntarily in the Services and you recognize that they may contain certain inherent risks. As the legal guardian for the client, who is a minor, you are choosing to provide consent for the client to participate in the Services. You have discussed the potential benefits and possible side effects of Services with me and you agree that you expressly assume the risks of receiving Services. By signing below, you agree that you voluntarily request and consent to our Services and our work together, and you understand and have been informed of the potential risks and you are voluntarily and knowingly assuming these risks. You have had an opportunity to ask questions and you agree to assume all risks during the Services in which you participate. You agree to take responsibility for your life and well-being and all decisions made before, during and after the Services are rendered.
You also understand and agree to disclose any and all medications that the client is taking and related services (e.g. other therapists the client is working with), recognizing that failing to disclose them could be conflict of therapy approaches, stall progress, or have potential negative reactions if you implement certain recommendations that I might offer.
You agree to disclose information requested from you about your child’s health, wellness, medication, supplements and other health conditions that we deem could impact our recommendations, treatment, and their health. You are affirming that you have stated all known medical conditions and answered all questions honestly and you agree to provide complete and accurate health information and notice of health changes at successive Appointments. If you suspect that your child has a medical or mental health emergency, issue or concern, you agree to inform me and/or my staff immediately.
4. Scheduling & Appointments
Contacting Me: I try to be attentive to my clients. Should you need to reach me between Appointments, please contact me between 9:00am -5:00pm AZ. My office and I will do our best to respond to you within 48 hours on weekdays. On weekends and holidays, we will do our best to reply to you by the next business day. E-mails, calls or texts to me related to your Services are for quick questions and you will receive brief responses. If you want to discuss something at length with me, I may request that we wait and discuss your question at our next Appointment.
Scheduling Appointments: Appointments (for screenings, evaluations) are scheduled by phone or through my confidential portal. The link can be found on my website or accessed through this link: https://go.thryv.com/site/illuminate/activity/dashboard
Screenings hosted by a school may be scheduled by the school and for a day the child is scheduled to attend. The day and time for recurring weekly appointments will be reserved once the therapy package has been paid for. Please be prepared to start and end your Appointments on time.
Rescheduling: If you need to reschedule an Appointment, you need to do so at least 24 hours in advance of your scheduled time by phone or email. Options for rescheduling include selecting a different day of the same week or adding an additional appointment to your schedule the following week.
Canceled & Missed Appointments: Our time together is important. If you need to cancel your Appointment, you need to do so at least 24 hours in advance of your scheduled time by email or phone. If you do not contact me at least 24 hours in advance, this will be considered a missed Appointment. Missed Appointments may not be able to be rescheduled. I will do my best to reschedule you however, due to availability and planning this may not be possible.
Late Appointments: If you are late for your Appointment, it will still end on time, and no additional time will be added to the end of your scheduled Appointment. Should you be late, it will still be considered a full session and unable to be rescheduled even though you will only be seen for a portion of the Appointment as you will have forfeited the time you missed due to being late.
Being ready for an appointment: For in-home appointments, please have a designated space we will be able to work in with the least amount of distraction. For preschool and kindergarten aged children this may look like a living room space on a rug. For elementary aged children, this may look like a table and chairs. An adult is expected to be home for in-home appointments for the duration of the session. The therapist will not be able to supervise any other children (i.e. siblings) other than the one scheduled to receive services.
To optimize virtual appointments, kindly arrange a dedicated workspace for your student at a table, minimizing potential distractions. It's advisable to provide headphones equipped with a microphone. Before the session begins, please ensure that the battery/charger is in good condition to prevent any interruptions. Ideally, ensure that the camera is turned on and positioned in a well-lit area for optimal visibility during the session.
Collaboration between family and therapist is a core-value at Illuminate Family Workshop. For some families, it might be beneficial for the child’s adult to participate in therapy sessions to learn prompts and cues to carry-over skills after the session is over. However, every child is different and some do better without their adult in the room. We’ll communicate about this during our first sessions.
5. Fees and Payment
Fees: Fees for my Services are as follows:
Speech/Language Screening - Free of Charge
Our brief 15-20 minute screening serves as an introductory meeting between the therapist and your child. This screening can be scheduled either at your home or your child's school. Following the screening, we will provide recommendations for the next steps in the process.
Toddler Speech-Language Evaluation - $450
This evaluation is specifically designed for students under the age of 3 with concerns related to langauge development. It encompasses a 60-minute session, conducted either at your child's school or in the comfort of your home. Following the evaluation, there will be a 30-minute debrief session, and a comprehensive report with tailored recommendations will be provided.
Preschool Language Evaluation - $650
This evaluation is tailored for preschool-aged students who are non-speaking or minimally verbal. It includes a 60-minute session with the child, followed by a 30-minute debrief session with the family. A comprehensive report will be provided, detailing the communication profile and offering personalized recommendations.
Articulation Evaluation - $650
This evaluation is specifically designed for students with concerns related to speech sound development. It involves a 60-minute session with the child, followed by a 30-minute debrief session with the family. A comprehensive report, including a detailed analysis of the speech sound development profile and personalized recommendations, will be provided.
Comprehensive Speech-Language Evaluation - $850-$1,200
This assessment is designed specifically for preschool-aged and school-aged students with questions regarding language, articulation and learning environment. It involves two 60-minute sessions with the student, a 60-minute school observation, and concludes with a 30-minute debrief session with the family to review the collected data and discuss recommendations.
During the evaluation, we will gather data on various aspects, including articulation, expressive language, receptive language, fluency, voice, and oral motor mechanisms. Additionally, we will conduct a classroom observation to ensure a comprehensive understanding of the student's communication skills in different settings. For more information visit: https://www.illuminatefamilyworkshop.com/speech-screenings-and-evaluations
This comprehensive approach allows us to provide a detailed and personalized assessment, leading to well-informed recommendations for your child's communication development.
School Consultation - $180/hr
Our school consultation service facilitates communication between the therapist, the student's school team, and the family. This may include correspondence with teachers via email or phone, active participation in team meetings at school, educating teachers about the current therapy plan and progress, as well as providing consultations to parents.
Therapy Session Bundles
30 Minute Session Packages:
This option is exclusively available to students participating in school collaborations and partnerships.
# of sessions |
|
8 Sessions |
$720 |
16 Sessions |
$1,400 |
24 Sessions |
$2,050 |
60 Minute Sessions Packages
# of Sessions |
|
4 Sessions |
$720 |
8 Sessions |
$1,400 |
12 Sessions |
$2,050 |
Our approach involves tailoring recommendations for frequency and duration to align with each individual's unique goals. This monthly package format offers the advantage of securing a fixed day and time on my calendar, ensuring regular sessions to monitor and track progress. Upon purchasing a package, you'll acquire a corresponding number of "credits." These credits are flexible, allowing them to carry over into the following month and remain valid for up to 6 months. Additionally, sessions can be temporarily paused during Spring, Summer, and Winter breaks, with the option to resume once school is back in session.
Payment: All payments are prior to the service and can be conveniently paid online via debit card, credit card through a secure client portal. This also includes FSA and HSA accounts. Please note that chargebacks are not permitted and that by signing below, you are agreeing that you will make payment in full unless other arrangements have been made and documented.
Insurance: At this time, I am not a member of any managed care/insurance provider panels or plans. You may request a detailed, itemized “superbill” to be provided for you to submit to your insurance for reimbursement. It is recommended you check with your insurance provider to see what your out-of-network benefits are for speech therapy before we begin our work together.
Refunds: Our package structure at Illuminate Family Workshop is carefully designed to not only secure your spot in our calendar but also to deliver high-quality services, allowing you to make a meaningful investment of your time and energy into this transformative journey. Please be aware that, in line with our commitment to scheduling and reserving services, we do not offer refunds for any remaining sessions should you decide to discontinue services.
However, we understand that circumstances may change, and if you choose to discontinue services after your initial session, we are happy to accommodate by providing a 50% refund of the package cost. To initiate the refund process, kindly notify us via email at hello@illuminatefamilyworkshop.com at least 48 hours before your second scheduled session.
It's important to note that, based on my clinical judgment, if I observe that your student is nearing their goals and potentially ready to graduate from services, I may recommend transitioning to individual sessions instead of packages. This personalized approach ensures continued support that aligns with your child's evolving needs. Your understanding of these terms and potential adjustments to better suit your child's progress is greatly appreciated, as our ultimate goal is to provide optimal support for their development. If you have any questions or concerns, feel free to reach out to us.
Late Payments & Non-Payment: Your scheduled appointment is confirmed with the complete advance payment for indicated service. If services were held and completed and your invoice has not been paid for more than 60 days and arrangements for payment have not been agreed upon, you agree in advance that I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, you will be billed additional charges to cover the cost of time and expenses incurred by me in obtaining payment, including legal fees, and these costs will be included in the claim. In the case of collections, typically the information that is released to the bill collector is the client’s name, the nature of services provided, and the amount due. I hope I would not need to resort to collections to secure payment, but should that be the case, you are consenting to the release of this and any other relevant information should collections efforts become necessary.
6. Confidentiality & Disclosure
You consent to the use and disclosure of your identifiable health information and personal data for the purposes related to your Services. You understand that under HIPAA (the Health Insurance Portability and Accountability Act) and, if applicable, the General Data Protection Regulation (GDPR), you have the right to request restrictions as to how your identifiable health information is used or disclosed to others. Your identifiable health information includes health information as well as your demographic information that is collected from us and/or created or received by us, another health care provider, a health plan, your employer or a health care clearinghouse. It will be used to create recommendations, protocols and other suggestions based on your needs. This identifiable health information relates to your past, present or future physical or mental health or condition and identifies you, or there is reasonable basis to believe the information may identify you.
You understand that you have the right to:
- Request a copy of your health records
- Request a correction of information that you deem incorrect in your health records
- Request that your health information not be shared with certain individuals
- Request that your health information not be used for certain purposes (e.g., research)
- Request us to send a copies of your health records to whomever you wish
- Be informed as to who has read your records (for reasons other than treatment or payment)
- Specify how and where we may contact you
- Receive a paper copy of a full HIPAA Notice of Privacy Practices upon request
In general, the privacy of our communication is protected by law, and I can only release information about our work to others with your written permission; however, there are some situations in which I may be legally obligated to reveal some information about you, even without your consent. You understand that your confidential health information will not be disclosed anyone else without your written consent prior to access or disclosure, except in the situations outlined below or as allowable under HIPAA, including:
- If in my professional judgment I believe you lack the capacity or refuse to care for yourself and such lack of self-care presents substantial threat to your well-being or the well-being of others.
- If you threaten serious bodily harm or death to yourself.
- If you threaten serious bodily harm or death to another.
- If the abuse, neglect, or exploitation of a child, elder adult, or dependent adult is suspected.
- If you are involved in a legal proceeding and a judge issues a court order for your testimony.
- If you pursue civil or criminal legal action against me or if you make a complaint to a Professional Board about me.
- If release of information is otherwise required by law (e.g. reporting of medical errors, due to a court order or subpoena, requested under the Patriot Act).
In addition, you should be aware of the following limits to confidentiality and you consent to disclosure under these circumstances:
- I may find it helpful or required to consult with other medical health care professionals for the purpose of gaining professional supervision, support, education, and exchange of ideas. During such consultations, I make every effort to avoid revealing your identity. The consultant in these instances will be a medical or mental health care professional who is therefore also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important.
- Information that you allow me to exchange with other professionals or information that you might choose to provide via email, fax, or cell phone cannot be guaranteed confidential.
- Although rare and unexpected, it is possible that confidential information stored on my computer and protected by passwords and accessible legally only by me could be accessed illegally by others.
7. Termination of Relationship
You have the right to discontinue your Services at any time. If you or I determine that you are not benefiting or that it is no longer a good fit for either of us, either if us may elect to discontinue our work together if either of us believe that it is not in the best interest of your health or wellness. We agree to do our best to provide at least 14 days advance notice to the other via e-mail for you at the e-mail address you provide below and for me at my e-mail address treisha@illuminatefamilyworkshop.com should we wish to terminate our work together.
8. Limitation of Liability & Release of Claims
You waive and release the Practitioner from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which you may have or claim to have in the future against the Practitioner arising from your past or future participation in, or otherwise with respect to, anything related to and including the Services, to the fullest extent permissible by law. You agree to pay for all damages to any person and the facilities caused by any negligent, reckless, or willful action that you may take that may arise while receiving the Services or you are under the care of the Practitioner.
9. Signatures
You understand that by signing this Informed Consent Form, you acknowledge that it will apply to all current and future Services you receive. Your signature below indicates that you give consent, you have carefully read this Informed Consent Form, and you have had the opportunity to ask questions and address your concerns before signing it. You understand that by signing below you are voluntarily surrendering certain legal rights. Your signature also indicates that you understand and provide your informed consent to the issues related to the risks and benefits of the Services, and my policies related to confidentiality, fees and payment, and all other responsibilities and terms of this Agreement.