PlayWrite Therapy Consent for Treatment & Policies

Consent For Treatment
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent *

First NameLast Name
Parent (optional)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Primary)*
Please enter a valid phone number.
Phone Number (Secondary)
Please enter a valid phone number.
Email*
example@example.com
Referred By:*
Emergency Contact
Name*

First NameLast Name
Relationship to Child?*
Phone Number*
Please enter a valid phone number.
Allergy Alert / Dietary Restrictions
I, parent name* hereby assert that the above named child has the following allergies and/or food restrictions: insert allergies / food restrictions*
Consent for Treatment

I authorize and direct PlayWrite Therapy to perform appropriate assessment and treatment procedures with the above named child. I further authorize and direct PlayWrite Therapy, having assessed and/or treated the above named child to release any appropriate information acquired in the course of the assessment and treatment to the following agencies, facilities, schools, or related professionals:
School:
Medical Doctor:
Psychologist/Educational Therapist:
Speech Therapist/Physical Therapist:
Other:
Insurance & Policy Number (only if you plan to seek reimbursement):
Payment Agreement
- I have read and understand the attached letter stating policies of practice, including the cancellation policy.
- As a reminder: Cancelled appointments are charged a $100 fee to cover overhead expenses, except in the event of emergency or illness. Appointments cancelled less than 24 hours in advance are charged the full treatment rate.
- I agree to pay PlayWrite Therapy the full amount of any and all fees related to services rendered. Payment is expected at the time of service.
- I understand that if I am seeking reimbursement from my health insurance company, I must file a claim for benefits independently.
Fees Are As Follows:

Assessment & report: ............................$1300
Assessment w/school visit & report .......$1500
Treatment: .............................................$190/session (50 minutes)
Treatment Plan: .....................................$400 (includes review of records, written goals, and a parent meeting)
Consultation (one time appointment) ....$275/session (50 minutes)
Reports & Home programs: ..................$190/hour
Travel time: ...........................................$190/hour (billed in 15 minute increments)
Responsible Party Signature*

Clear
Responsible Party Name*

First NameLast Name
Relationship to Child:*

PlayWrite Therapy Policies

We are honored to assist you and your family with occupational therapy services for your child. Please read this information carefully so that you become familiar with our policies and methods of practice. Please initial at the end of each section.
Services Offered

We offer occupational therapy services including evaluation and treatment in the areas of sensory integration, fine motor, visual motor, handwriting, gross motor, self-care, and oral motor/feeding skills.

We provide clinic-based therapy and home and school consultation. Following a complete evaluation/screening, a treatment plan will be recommended (duration and frequency) as appropriate. Treatment goals will be developed at that time. If there is no history of ongoing therapy or assessment within the past year, an evaluation is necessary prior to the initiation of therapy.
Initials*
We will accept an occupational therapy evaluation completed at another center. Prior to starting treatment, we will need to review the evaluation and any other relevant records. It is possible that we will need to do additional testing during your child's initial treatment sessions. Following 4-6 treatment sessions, we will write up goals and a treatment plan with your input, and schedule a one hour meeting with you to review our observations and collaborate on suggested goals. The fee for this service is $400.
Initials*
Cancellations

Our goal is to find a treatment time that is mutually convenient to see your child. This treatment time is specifically reserved for your child. If you need to cancel your session, please give at least a 24-hour notice via email at rebecca@playwrite.org or leave a message/text at 415-713-1003. When a session is canceled, you will be charged a $100 cancellation fee to cover overhead expenses. However, if the session is a no show or is canceled with less than 24 hours notice, the full amount of the session is charged. Cancellation fees are waived in the event of an emergency or illness; or if your session falls on the following holidays: Martin Luther King, Jr. Day, President's Day, Memorial Day, 4th of July, Labor Day, Thanksgiving week, and the two week school break at Christmas/New Year's.
Initials*
We are unable to hold treatment times for extended cancellations, such as summer break. If you need to cancel more than 3 sessions in a 3 month period, we will need to offer your treatment spot to another child on our waiting list. When you return, we will do our best to find a therapy time for your child.
Initials*
A two-week notice is required from families wishing to discontinue services. You are responsible for attending sessions during this time or paying for the missed appointments.
Initials*
Parent/Professional Conferences

Brief conversations with parents/caregivers following therapy sessions are considered an essential part of the therapy program. Scheduled conferences outside of treatment sessions with parents and/or professionals will be billed at the regular treatment rate. Progress reports can be written for your child upon request. Please allow 2-4 weeks for any testing to be completed and a report to be written. Reports are billed at the regular treatment rate.

Email should be used for scheduling purposes only. If you would like to discuss your child’s progress, have specific treatment questions, or any concerns that you would like to discuss outside of therapy sessions, please schedule a meeting with your therapist. Meetings can be done over the phone or in person. We welcome your questions and look forward to working together to provide a comprehensive therapy program, while maintaining your child’s privacy.
Initials*
Payment

Payment is required upon arrival to each therapy session and at the first assessment session. We accept credit cards or checks as payment. If you pay by credit card, we will only need to swipe your card once and after that you will be billed automatically after each treatment session. You will be sent an invoice marked paid after each therapy session. Your credit card number will be kept securely in our credit card payment system.
Initials*
Insurance

If you are seeking reimbursement from your health insurance company, you must claim benefits independently. We will provide insurance codes for reimbursement; however, we do not accept payment from insurance companies and cannot guarantee reimbursement. You are responsible for full payment for each therapy session.
Initials*
Should be Empty:

Consent For Treatment

Emergency Contact

Allergy Alert / Dietary Restrictions

Consent for Treatment

Payment Agreement

Fees Are As Follows:

PlayWrite Therapy Policies

Services Offered

Cancellations

Parent/Professional Conferences

Payment

Insurance