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THERAPY SPOT CHILD CONSENT FORM
FORM NAME
DESCRIPTION
Parents First and Last Name
*
Please check all that apply: I provide consent to Therapy Spot to take PHOTOGRAPHS of my child 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 my child 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 my child 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:
*
Physical Prompting
Prompt Oral Motor Prompting
I provide consent to Therapy Spot to assist my child with toileting during:
*
1 on 1 S-LP/BCBA/ABA Therapy at GABA School/At home/school or in clinic
I do not consent (not applicable)
I authorize Therapy Spot to be permitted to REVIEW AND OBTAIN copies of all hospital, medical, vocational and other related records concerning my child and to discuss pertinent information with any professionals involved in my child's treatment.
yes
no
[if error]
I give permission for Therapy Spot to share my child's information both informally and via written reports with:
*
Insurance Company
Family Doctor
Lawyer
Occupational Therapist
Physiotherapist
Psychologist
Social Worker
Case Manager
School, Tutor
Other
I give permission to Therapy Spot for the following individuals to observe/participate in my child's 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 for my child
yes
no
I consent to Treatment at Therapy Spot for my child
yes
no
Please upload any documents you feel would be helpful for the therapist to read ahead of time
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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".
*
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