Evaluation Policies Form

EVALUATION POLICIES AND AGREEMENT

Revised September 2017

Welcome to Center for Developing Kids. We are pleased to serve 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 his/her family or typical everyday environments; and ultimately enable the child to engage in activities that give meaning to his/her life. In order to serve you and your child effectively and to eliminate misunderstandings, please carefully read the Evaluation Policies and Agreement below and sign at the bottom of the page.

PRIOR TO EVALUATION

  1. All forms must be submitted online.

  2. Unless paying privately, authorizations must be in place prior to the evaluation. Please call 626-564-2700 to ensure this process is complete.

  3. If using insurance it is recommended that you check with your insurance company to ensure that the services you are requesting are a covered benefit per your specific policy. We will also call the insurance company once you have provided your information. If our front office indicates that a prescription is required, you must obtain this from your child's doctor and furnish the prescription to us prior to the evaluation appointment.

  4. Once an evaluation is completed, if treatment is recommended we will attempt to place your child on the schedule, however, we cannot guarantee immediate availability.

WHAT TO EXPECT AT THE INITIAL EVALUATION APPOINTMENT

Insurance: A credit card MUST be left on file to pay for deductibles and/or copayments. Your insurance card must be presented. Center for Developing Kids will bill your insurance company.
IN THE EVENT THAT YOUR INSURANCE COMPANY DOES NOT PAY FOR THE EVALUATION COMPLETED, YOU ARE RESPONSIBLE TO PAY (SEE ATTACHED ASSESSMENT RATES). There will be no reimbursement for past services provided.
An explanation of charges will accompany your payment receipt and invoice. *

Private Pay: You will be expected to pay for services rendered on the day of the evaluation. You may use a credit card or pay cash.

All Clients: Upon arrival, please sign in and either alert the front desk office staff that you are a new client or you may use the telephone intercom to announce your child's arrival. If someone does not respond to you within a few minutes please alert the front office staff.

The initial evaluation typically takes about 1 to 1.5 hours. Upon completion of the evaluation, the therapist will briefly discuss your childs performance but will not likely make a specific recommendation regarding the necessity of therapy services until the assessments have been scored and interpreted. Every attempt will be made to provide you with a written report along with recommendations within two weeks of the evaluation appointment.

CONDITIONS OF TREATMENT

  1. CONSENT TO TREATMENT
    I hereby consent to the administration and performance of all diagnostic procedures and treatments within the realm of current standards of practice, which in the judgment of my child's therapist may be considered necessary or advisable.

  2. DISCRIMINATION
    Center for Developing Kids does not discriminate on the basis of race, religion, sex, national origin, sexual orientation, age, or disability.

  3. RELEASE OF INFORMATION
    I hereby agree that Center for Developing Kids 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, Center for Developing Kids may disclose portions of my child’s records to funding agencies such as health care insurance plans, school districts, and regional centers.

  4. FINANCIAL AGREEMENT
    I hereby agree that in consideration for services to be rendered by Center for Developing Kids, I shall make prompt payments to the account of Center for Developing Kids 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.

  5. FEES

    Therapy: Occupational, Physical or Speech $130/hour
      Feeding Follow Up Intervention $130/hour
    Assessment: Occupational, Physical or Speech Therapy $550
      Sensory Integration and Praxis Tests (SIPT) $975
      Team Feeding $850
      Social Skills $192.82
    Reports: Annual re-assessment, Progress, Equipment $130/per report
    Programs: Kids Connection (small group social emphasis) $95/session
      Write On (handwriting clinic one week in summer) Check website
      SUNKIDS summer program (three weeks in summer) Check website
      Therapeutic Listening $130/month
    Meetings: Community (inservices, due process, hearings), Family $130/hour
    Late Pick Up:   $1/minute
  6. CONSENT TO PHOTOGRAPH
    I hereby agree to allow Center for Developing Kids 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 Center for Developing Kids. This visual record may be used for teaching and training activities and/or as part of my child’s medical/developmental record as Center for Developing Kids 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.


Please sign below.