Teletherapy Intake & Agreement

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Please complete this form if you are interested in signing up for The Therapy SPOT"s teletherapy services. We will do our best to work within your provided day/time preferences and to schedule your child with his/her current treating therapist(s) for best continuity of care.

Child's First Name *

Last Initial (not full last name) *

Child's Date of Birth *

YYYY

Best email to contact you with instructions *

Best phone number to contact for scheduling *

Therapy you are interested in *

occupational therapy

speech therapy

whatever my therapist(s) recommend(s)

Required

What days and times are you available for these services? *

Which therapist(s) would you prefer to work with (check all that apply)? *

Paula (speech)

Julianne (speech)

Katie (speech)

Andrea (speech)

Jessica (OT)

Jaimie (OT)

Karen (OT)

Stefanie (OT

Krisann (OT)

Whoever my current therapist(s) recommend(s)

Whoever is available within my preferred days/times

Required

Do you have access to a printer at home, if needed for printing handouts or other resources? *

Option 1

Please check which of the following you have access to *

Microsoft Word (or at least can open word documents)

Adobe reader (can open PDF files)

I'm not sure

Other:

Required

By typing your name below, you agree that The Therapy SPOT will bill your insurance for teletherapy services and that you understand the following: any co-pays or deductibles that apply will be your responsibility; in the event that this type of service is not covered by your insurance company, you will be responsible for our discounted private pay rates (30 min= $40; 45 min= $60; 60 min= $80); payment for service is expected upon receipt of a statement, which will be emailed or mailed to you, pending your preferences. TYPE YOUR NAME BELOW TO INDICATE YOU AGREE WITH THE ABOVE STATEMENT: *

Once this form is received by our staff, we will review your current therapist's recommendations regarding teletherapy and then contact you to schedule an appointment. At the time of scheduling, you will receive instructions regarding how to access teletherapy services, items to have prepared in advance. In addition, your therapist may contact you directly to ensure you have certain supplies handy for the session. *

I understand that I must review the set up and instructions information that is emailed to me and reviewed with me during scheduling

I understand that my therapist may contact me separately to ensure I have items prepared for the session

I understand all of the above

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