416-546-3044
office@therapyspot.ca
About Us
Teletherapy
FAQ
Blog
Contact Us
staff login
Client Login
home
Service Areas
School Programs
Groups & Workshops
Service Handbooks
THERAPY SPOT ADULT CONSENT FORM
FORM NAME
DESCRIPTION
First and Last Name
*
Please check all that apply: I provide consent to Therapy Spot to take PHOTOGRAPHS of me for the purposes of:
*
Therapy Progress tracking
Research
Advertising
Education of students and/or other professionals
Check all that apply: I provide consent to Therapy Spot to take VIDEO of me and use it for:
*
Therapy Progress tracking
Research
Advertising
Education of students and/or other professionals
Check all that apply: I provide consent to Therapy Spot to take AUDIO RECORDINGS of me and use it for:
*
Therapy Progress tracking
Research
Advertising
Education of students and/or other professionals
Check all that apply: I provide consent to Therapy Spot to use:
*
Prompt Oral Motor Prompting
Not applicable
I authorize Therapy Spot to be permitted to REVIEW AND OBTAIN copies of all hospital, medical, vocational and other related records concerning me and to discuss pertinent information with any professionals involved in my treatment.
*
yes
no
I give permission for Therapy Spot to share my information both informally and via written reports with:
*
Insurance Company
Family Doctor
Occupational Therapist
Physiotherapist
Psychologist
Social Worker
Case Manager
School
Tutor
Other
Other
I give permission to Therapy Spot for the following individuals to observe/participate in my therapy session for training purposes:
*
Therapy Spot S-LP
Therapy Spot CDA
Therapy Spot IT
Therapy Spot University graduate student,
Therapy Spot volunteer.
I Consent to an Assessment at Therapy Spot
yes
no
I Consent to Treatment at Therapy Spot
yes
no
Please upload any documents you feel would be helpful for the therapist to read ahead of time
Uploading Files. Please Wait.
Drop a file here or click to upload
Choose File
Maximum upload size: 33.55MB
My name below verifies that I have read, understood and have completed this form. I am consenting to all above checked fields and/or all fields with a response of "yes".
*
Submit