Nature of treatment. Medication □ Counselling □ Surgery □ Physical Rehabilitation □ Please give details of the treatment plan and frequency of treatments: If none, please explain:
Nature of treatment. Treatment is being provided by licensed professionals on staff and/or through our referral list. Participation can result in numerous benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. PAYMENT & FEES: The maximum fee for therapy/consultation is $125.00 however the fee may be reduced based on your ability to pay, your annual income, and what portion your insurance company contributes to payment. Therefore, as these conditions change your fee may be adjusted accordingly, never exceeding $125.00. You are expected to pay for services at the time they are rendered unless other arrangements have been made. Services are rendered and charged to the client, not to the insurance company. Your therapist will provide you with a receipt to submit to your insurance company for reimbursement. There is a $20.00 charge for returned checks. LIMITS WITH ONLINE SUPPORT: Although confidentiality and privacy are maintained professionally, confidentiality and privacy in psychotherapy sessions involving the internet cannot be guaranteed due to the insecure nature of internet connections. Oaks Counseling, Inc. is not liable for internet security breaches outside of our control. "Synchronous" online sessions (when my therapist and I will be online simultaneously) must be scheduled and adhered to just as conventional office sessions require, so that both parties can rely upon a schedule. Cancellations less than 24 hours in advance are subject to the full fee for the appointment time.
Nature of treatment. You acknowledge and agree that the Treatments may consist in whole or part of experimental procedure and methods, including without limit Acupuncture, Intravenous Micronutrient Therapy, Minor Surgery, Prolotherapy Platelet Rich Plasma therapy, and Cellular Therapy, on which no governmental (including the U.S. Drug Administration (“FDA”), scientific or medical authority has confirmed the safety or efficacy therefore, You acknowledge that the safety and efficacy record of the Treatment is based only on empirical and anecdotal evidence, which only shows that the Treatment appear to be relatively safe and effective. We have informed you that the Treatments MAY alter, address or decrease Your pain, symptoms or complaints, but also may have no effect. (Initials)
Nature of treatment. □ Medication □ Surgery Please give details of the treatment plan and frequency of treatments: If no treatment, please explain: □ Physical Rehabilitation □ Counselling 8. The City of Xxxxxxxx has a proactive modified work /work accommodation policy. Even though your patient may not be able to return to their own job, suitable modified or accommodated work will be provided. The information you provide will be used to develop a full return to work plan for your patient up to and including a return to regular duties. Please complete the applicable options: □ is/was fit to work without restrictions on: (date) □ is/was fit to work with the following medical restrictions on: (date) Duration: Complete Restrictions Below □ is unfit to work. Prognosis for □ Full recovery (date) or □ Possible return to modified duties: (date) Physical Restrictions: The following chart provides an outline of accepted practice physical demand levels. Please select the level that best meets your patient’s current ability for Lifting – Carrying – Pushing/ Pulling (force weight for pushing/pulling). A RTW plan will be developed with the current ability as the starting point and progressing to meet the demands of their job at the end of the RTW plan. Physical Demands Level Occasional 0 – 33% of workday Frequent 34 – 66% of workday Constant 67 – 100% of workday □ Very Heavy Over 100 lbs Over 50 lbs Over 20 lbs □ Heavy 100 lbs 50 lbs 20 lbs □ Medium 50 lbs 20 lbs 10 lbs □ Light 20 lbs 10 lbs 10 lbs
Nature of treatment. Medication □ Counselling □ Surgery □ Physical Rehabilitation □ If none, please explain:
