Authorization for Treatment. I, authorize treatment by The Talking Place, Child and Adolescent Counseling, LLC. Date: Signature: Relation to Patient:
Authorization for Treatment. I have read, fully understand, and agree to the MJCCA Preschools Authorization for Treatment.
Authorization for Treatment. If your pet becomes ill during his/her stay with us, a veterinarian will examine your dog or cat. We will make every attempt to contact you at the numbers you provide should your pet become ill while with us. Medical treatment will be provided at the discretion of the veterinarian on duty. All costs associated with any medical care given while boarding will be at the owners’ expense and due upon your pet’s release.
Authorization for Treatment. When providing speech language pathology services, health care laws require us to obtain authorization from the patient or parent/guardian to provide services. This authorization is your agreement to allow Talk Play Learn Speech Therapy and its employees to render care within our scope of practice. I agree to allow Talk Play Learn Speech Therapy to provide speech-language pathology services for myself or my child/person in my care. In addition: ☐ I agree to attend scheduled therapy sessions (see attendance policy). ☐ I agree to participate in treatment, as appropriate. ☐ I understand that there may be work assigned for home practice. I agree to engage with home practice to help with treatment goals. Print Client’s/Xxxxx’s Name Print Parent/Guardian’s Name & Relationship to Client Client/Guardian’s Signature Date An initial evaluation can be provided at the request of the client/client’s parents; however, we are not required to conduct our own independent evaluation to establish a treatment plan in order to bill for our services. ● Parents can provide their child’s school, hospital, and/or previous private practice evaluation report as a means of generating speech goals, if available. ● If the evaluation report is dated one or more years ago, the speech-language pathologist may recommend reevaluation to obtain an updated account of the client’s ability level. Speech Therapy services will be provided based on goals agreed upon by both parties in order to best serve your child. Goals can be established through one or more of the following means: administered evaluations/reports; outside evaluations/reports; observations; and parent requests. Session structure: ● sessions are 45 minutes in length. Goals for speech therapy will be formed based on initial evaluation results, which includes parent input. As treatment begins, a Plan of Care will be provided to client/parent/guardian as applicable. A POC will include some information about current skills, as well as goals for therapy. Approximately every 3 months or after 10-12 sessions, a progress report will be provided with information about the child’s goals, progress toward those goals, and recommendations for next steps.
Authorization for Treatment. In the event of injury or illness, the Applicant authorizes LifePoint Church personnel, staff or designates to seek and obtain such emergency or medical services for people as may be deemed necessary at the time.
Authorization for Treatment. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. This completed form may be photocopied for trips out of camp. I also give permission for routine medical care as per the camp physician’s standing orders for my child at Xxxx Xxxxxx YMCA. I understand the camp fees do not include health and accident insurance and I will be responsible for any and all charges incurred in obtaining prompt medical attention. Medication Authorization : When Bringing Medication to Camp: GUESTS (herein referred to as “the undersigned”): MEMBER CONDUCT I agree to abide by all rules and regulations of the YMCA of Metropolitan Hartford (hereafter “YMCA”), and I understand that failure to act in accordance with the rules may result in expulsion from the YMCA . INSURANCE I understand that the YMCA does not provide any accident or health insurance for its members or participants and it is my responsibility to provide such coverage. PROPERTY LOSS I understand that the YMCA is not responsible for personal property lost, damaged or stolen while using YMCA facilities or participating in YMCA programs. ASSUME FULL RESPONSIBILITY I hereby assume full responsibility for and risk of bodily injury, death or property damage while in, upon, or about the premises of the YMCA and/or while using the premises, or any facilities or equipment thereon or participating in any program affiliated with the YMCA. RELEASEE, WAIVE, DISCHARGES I hereby release, waive, discharge and covenant not to sue the YMCA, its directors, officers, employ- ees, and agents (hereinafter referred to as “releases”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damages, and any claim or demands therefore on account of injury to the person or loss of
Authorization for Treatment. I hereby certify that I have read and that I fully and completely understand this Informed Consent for Neurofeedback Training, and I have signed this Informed Consent knowingly, freely, and voluntarily. I understand the policies, expectations, and nature of this treatment as explained above. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained by any neuropsychological. I understand that while my treatment is designed to be beneficial, this facility makes no guarantees about the outcome of this treatment program. I am willing to make a personal commitment to participate to the best of my ability in all steps of the treatment program, though I understand that I am free to withdraw from this treatment at any time. I understand that my failure to comply with my recommended treatment program (such as assignments and regular participation in sessions) could prevent the treatment from working effectively. ______________________________________________ Patient Signature (Guardian signature if patient is a minor) Date The Staff at Neurohealth Associates is fully trained to answer all of your questions regarding scheduling and logistics related to the office. It is of great importance, to all of us, that you be treated with the utmost of respect as demonstrated in our communication style and our willingness to be of assistance. In turn, we ask that you return the same level of respect back to our Staff and our other patients. This is including but not limited to:
Authorization for Treatment. Should the need for medical attention arise; (and in case of our unavailability), as parents or legal guardians, we want the MJCCA and/or staff to arrange and authorize medical treatment as necessary for our child. In the event of an emergency, I hereby give permission to the physician selected by the director or other MJCCA official to order x‐rays, routine tests, and treatment for the health of my child. In the event that I cannot be reached in an emergency situation, I hereby give permission for a physician selected by the preschool director or other MJCCA official to hospitalize, secure proper treatment for, and order injections and/or anesthesia and/or surgery for my child. I authorize any physician, nurse or other health care provider to communicate with the staff and director of MJCCA Preschools, or his/her designee, about my child’s medical condition, treatment and/or prognosis. I further authorize the director to discuss any medical conditions with his/her designee, or the child’s teacher when the director, in his / her sole discretion, believes such communication to be in the best interest of the child. I, the parent/legal guardian, assume all risks and hazards incidental to the conduct of activities and transportation to/from the activities. I understand that aspects of the MJCCA preschools & Xxxxx may be physically and emotionally demanding. Both my child(ren) and I agree to follow any and all rules, guidelines, and safety instructions that may be provided by MJCCA staff. I recognize the inherent risk of injury or disability in activities. I understand that each participant must assume the risk of injury or disability that could result from any of these activities. I hereby release, indemnify, defend, save, and hold the MJCCA its officers, directors, trustees, employees, members, agents, and activity providers harmless, with respect to any and all claims or liability for any injury to my child(ren) from participation in any and all activities and all claims by or on behalf of myself, my child(ren), or third parties for loss or damage unless the alleged loss is solely the result of the MJCCA’s gross negligence or misconduct. Upon arrival and dismissal, please park your car in a designated parking place and check in at the school office. We ask that you limit your time in the building to 10 minutes, as our parking spaces are limited. If you know you will be longer than 10 minutes, please park in the main MJCCA parking lot. Please also make sure t...
Authorization for Treatment. I hereby consent to and authorize all therapy treatments, which in conjunction with the judgments of the attending physician may be considered necessary or advisable for the diagnosis or treatment of the above named patient at Core Physical Therapy. I realize that I am a integral part of the rehabilitation process and will be sufficiently educated about treatment and alternatives before they are performed. Please initial . Date / / Signature (Parent or guardian signature if patient is a minor) Patient Name
Authorization for Treatment. In the event of injury or illness, the Applicant authorizes Koinonia Church personnel, staff or designates to seek and obtain such emergency or medical services for people as may be deemed necessary at the time.
