Consent for Treatment
This form serves to demonstrate clear boundaries and expectations of your therapist as well as the risks of participating in services.
Due to the highly interactive nature of the services provided by Music Plus, our therapists may need to make physical contact in order to complete or correct a movement. This type of therapeutic touch may present in several ways including but not limited to: providing deep pressure for sensory regulation, correcting body positioning during movement activities, providing hand-over-hand assistance while playing instruments if necessary, de-escalating aggressive behavior, removing an individual from a dangerous location, neutralizing self-harming behaviors, or deterring elopement.
Much of the latter is typically in line with the recommendations of the individual's behavioral professional, if available. During all cases of therapeutic touch, your Music Plus therapist will never engage any part of the body covered by a swimsuit. (This includes the thigh area and the chest for both sexes.)
All Music Plus therapists demonstrate sound professional judgement concerning injury prevention to any party. While your therapist will be guiding you in safe interventions, there is a minimal chance of injury. You can help reduce this liability by clearly communicating what you know to be typically hazardous or painful for your specific movement, behavior and safety needs.
I ________________________________ (Parent/Power of Attorney/Self/Guardian),
(Please choose one or more)
do not give any permissions
for ___________________________(Individual Receiving Services),
to receive therapy services provided by Music Plus - Therapy Services of Boulder LLC. I have read and understand the informed consent related to this therapy and I understand both the risks and benefits of receiving these services
as of the following date.
A copy of your responses will be emailed to the address you provided.
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