Welcome to Center for Developing Kids, Inc. (CDK). We are pleased to work with your child and family. Our mission is to provide children with the opportunity to attain their highest developmental potential using a collaborative and caring, multi-disciplinary team approach. We strive to provide quality therapy services, which do not separate the child from the context of the family or typical everyday environments, and ultimately enable the child to engage in activities that give meaning to his/her/their life. In order to serve you and your child effectively under a mutual understanding of our guidelines, please carefully read the following policies and sign at the bottom of the page.
CONSENT TO TREATMENT/ASSESSMENT
I hereby consent to the administration and performance of all evaluation procedures and treatments within the realm of current standards of practice, which in the judgement of my child’s therapist may be considered necessary or advisable.
CONSENT TO TELEHEALTH TREATMENT
CDK may recommend services through telehealth if clinically appropriate. I understand that my child will be receiving care through interactive audio, video, and other telecommunication technologies with a therapist who is not in the same physical location as me and my child. I understand that I am expected to provide a safe environment with minimized distractions for my child to participate in telehealth treatment. There is a risk that the quality of my child’s telehealth services will be diminished based on the difficulty of communicating and transmitting information without the benefit of being physically present and receiving non-verbal cues, and that there is greater risk of distraction from participants at remote locations. CDK, my child, and I will see and hear each other electronically, but some information the participants would ordinarily get in-person will be unavailable. There is a risk that, in the event of an emergency, my child and I will be alone and without the benefits of in-person interaction to support us through a moment of difficulty. There is a greater risk of intentional or unintentional violation of the confidentiality of client/patient information when transmitted electronically resulting in risks such as interception, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. There is a risk of technology failure and interruption by a connectivity problem. I will need access to, and familiarity with, the appropriate, working technology for my child and me to participate in the services provided by CDK, with a risk of corruption or technology interruptions. I also agree that my child and I are responsible for timely attendance, and that I remain responsible for adhering to CDK’s “Third-Party Funders,” “Parent Presence,” and “Attendance” policies, and the cancellation fees for missed telehealth appointments.
CONSENT TO USE OF THERAPEUTIC EQUIPMENT
I, on my behalf and on behalf of my child, fully understand that there is a risk of personal injury to my child in participating in play-based activities and other physically active games through the programs provided by CDK. I am aware that my child is engaging in physically active games and/or therapeutic activities, which could result in injury. I am voluntarily allowing my child to participate in these activities and assume all risks of injury that may result. I personally, and on behalf of my child, agree to hold no individual or corporation responsible or liable for any injuries and associated costs that my child receives on account of these activities, including but not limited to CDK, or it’s officers, employees, agents, aides, therapists, assistants, successors, instructors, insurers, or assigns (hereinafter “Releases”). I further agree to waive any claims or causes of action against and to hold harmless said Releases for any injuries or damages which my child suffers or might suffer as a result of the conduct of any person during or in conjunction with said physically active games or therapeutic play-based activities.
CONSENT TO PHOTOGRAPHY
I hereby agree to allow CDK to take and/or use any pictures/tapes/videos/films of me or my child with my full knowledge and consent as a client of CDK. This visual record may be used for teaching and training activities and/or as a part of my child’s medical/developmental record as CDK may deem proper. My child’s identity will not be made public without my expressed permission for a specific occasion or purpose. Any use of my child for public relations will also require my specific permission and knowledge.
CONSENT FOR EMERGENCY TREATMENT
As the authorized representative, I hereby give consent for CDK, to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D), osteopath (D.O.), or dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child. My signature at the bottom of this form testifies that I am the authorized representative of the child named on this document. Further, I will be responsible for the charges for any medical or dental treatment or hospitalization rendered by reason of this authorization.
I understand that in order to attend in person services, households must follow current Pasadena Public Health quarantine/isolation guidelines in case of a COVID-19 exposure or diagnosis (suspected or confirmed). I understand that if a child (or someone in the child’s home) experiences any symptoms of illness, the child should participate in telehealth until all symptoms (including, but not limited to, fever, vomiting, diarrhea, nasal congestion, cough, sore throat, skin irritation) have been fully resolved for at least 24 hours without medication. In the event that mild symptoms persist for more than 5 days, children may be allowed to return in person after presenting a doctor’s note indicating they are not contagious and/or a negative COVID-19 test. I understand that if a child shows symptoms of illness while receiving in person services, CDK staff will separate them from peers and contact caregivers for immediate pick up.
RELEASE OF INFORMATION
I hereby agree that CDK may release information, either written or verbal, regarding my child’s medical status and progress to professionals who have been or are currently involved in the treatment of my child. I hereby agree that, to the extent necessary to determine eligibility for services and to obtain reimbursement, CDK may disclose portions of my child’s records to funding agencies such as health care insurance plans, school districts, and regional centers.
ATTENDANCE AND CANCELLATIONS
It is extremely important to consistently attend appointments on time and avoid unnecessary cancellations. All cancellations must be sent to email@example.com. I understand that there are fees for late cancellations of clinic, and home-based sessions, those cancelled less than 24 hours prior to the appointment time. These fees start with the 4th occurrence ($50) and increase with the 7th occurrence ($75). There are fees for “no shows,” sessions that are not attended and not cancelled in advance of the session start time ($165). Sessions are considered a "no show" if I have not communicated with CDK within the first 15 minutes of the session. Late cancellation and no show fees are subject to change at any time. At least 75% of sessions must be attended on time in order to maintain a standing appointment time. If 25% or more appointments are missed in a 3 month period, my child’s therapy may be terminated.
VACATIONS AND EXTENDED ABSENCES
If two consecutive treatment sessions are cancelled or missed, for example due to vacations or serious illness, that appointment time may not be reserved.
I hereby agree that in consideration for services to be rendered by CDK, I shall make prompt payments to the account of CDK as bills are presented. I agree to pay interest at the legal rate should the account become delinquent, and if it becomes necessary for the account to be referred to an attorney for collection, I shall pay the actual attorney’s fees and collection expenses.
An explanation of charges will accompany my payment receipt and invoice. It is my responsibility to notify the front office at CDK if there are changes to my child’s insurance. In the event that my insurance or other funding agency does not pay within 90 days for rendered services, regardless of the reason, I am responsible for payment. I understand that school districts fund therapy services only on days when school is in session and my child attends school. School districts do not fund during school calendar vacations or holidays unless otherwise indicated in writing. Occasionally, with written permission from the district, schools may fund a session when my child’s school is out. I understand that it is my responsibility to obtain and monitor my child’s school calendar and pay privately for sessions that are not covered by the school district.
Therapy sessions are provided individually or in group settings depending on the service/clinical recommendation. If my child is receiving therapy in a home or community, a caregiver must be present at all times. If my child is receiving therapy in the clinic, caregivers may remain in the waiting room or participate in the session as long as they are directly with their child and therapist. I understand that observing from afar, using cell phones, reading, or using a computer is not permitted within the clinic treatment space.
SIBLINGS AND ACCOMPANYING CHILDREN
I understand that caregivers are responsible for supervising all children brought to the CDK waiting room, and that only children under direct care of a CDK therapist may use equipment and toys in the treatment space.
DROP-OFF AND PICKUP
I understand that children must be monitored in the waiting room and cannot be dropped off unattended. If I or another caregiver is leaving the clinic, I/he/she/they must provide a phone number at the front desk in case of an illness or emergency. I understand that caregivers are expected to arrive at the clinic 5 minutes prior to the session ending for a prompt pick up. There is a flat fee of $10 plus $2/minute late fee for pickups after the end of a session.
END OF SESSIONS
I understand that discussions with caregivers about activities and goal progress are part of intervention. Therapists and children may arrive in the waiting room prior to the session ending to account for this.
I understand that CDK may contact or release my child to emergency contacts I list on this form if a primary guardian is not available at the end of a session or program, or in the case of an emergency.
Following an emergency event, assuming conditions are deemed safe, children will be released to their guardians. If it is not feasible for a guardian to pick up a child, employees will take children to a verified safe location determined by the American Red Cross and/or communicated by the National Emergency Broadcast System. In an immediate building evacuation, employees and children will be instructed to assemble at the nearby Lamanda Park Branch Library.
Yearly evaluations are conducted for private pay clients per standard best practice guidelines. Evaluations for services through a funding agency are conducted according to the agency’s guidelines.
At times, therapists will take time for meetings, continuing education, vacation, or sick time. When this impacts scheduled appointments, CDK will provide coverage whenever possible.
CDK collaborates with accredited universities throughout the country by accepting occupational, physical, and speech therapy interns as part of fieldwork/internship programs. I understand that when my child’s therapist is a clinical instructor, it is likely that an intern will participate in all aspects of my child’s treatment with supervision from their clinical instructor(s).
CDK strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability. I understand that I and other guardians of my child are expected to participate in this endeavor and show mutual respect for members of our community.
This section describes how medical information about your child may be used and disclosed, and how you can get access to this information. Please review it carefully.
* Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permissions.
** If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.
I have reviewed, understand, and agree to the above policies and Notice of Privacy Practices.
Please sign below.