client services contract html
Hill Country Speech Therapy, PLLC
12505 Rush Creek Ln, Austin TX 78732 | email@example.com | (512) 368-2238
CLIENT SERVICES CONTRACT
Your scheduled therapy time is reserved time for your child and the speech pathologist. A great deal of time and effort is spent preparing for your child’s therapy session. If you must cancel a therapy session we request that provide us with 24 hours advance notice. Late cancellations and no-shows are subject to a fee equivalent to the regular visit.
There will be times when your speech pathologist will need to cancel therapy. When notified, you will have the opportunity to re-schedule or cancel the session.
Please be on time for your appointment. If you are late for an appointment it may be necessary to shorten your child’s therapy session in order to stay on schedule for other clients. In the event your child’s therapy is shortened, you will be charged for a full session.
Therapy sessions are scheduled in 30 or 45-minute increments. The last few minutes of each session is reserved to review your child’s progress and ask questions. There will be no therapy scheduled on most Texas State and Federal holidays.
Date: _______ / _______ / _____________
Payment is due at the time services are rendered. We accept cash, checks and credit card for services. Checks should be made out to Hill Country Speech Therapy, PLLC. We accept some insurance plans as payment for services. Once insurance coverage is verified, you will be expected to pay your co-pay each visit. Processing of insurance does not relieve you of your financial responsibility.
Bank returned checks will be charged $30 processing fee. ___________ (initial)
I understand that I am financially responsible for all charges provided for therapy, evaluation and consultation services. ___________ (initial)
After initial evaluation and throughout the duration of therapy the speech pathologist will discuss your child’s specific needs with you. Services for your child will be delivered based upon mutual agreement but ultimately it is you the parent/guardian that bears the responsibility to bring the child’s goals to therapy. Goals cannot be attained without practicing what is learned during therapy in the home environment. As the parent/guardian you will play an active role in your child attaining his/her goals.
To the fullest extent permitted by law, I ______________________________________________________________ hereby release Hill Country Speech Therapy, PLLC from any claims or damages of any kind or nature, known or unknown, suspected or unsuspected, disclosed or undisclosed related from __________________________________________________ (child’s name) participation in therapy. This release is binding to me and my heirs, executors, agents, administrators and assigns.
Date: _______ / _______ / _____________ Name (printed):
Michele Reeder, M.A., CCC-SLP
Michele received her Bachelor of Science degree in Speech Pathology and Audiology from Northern Arizona University and her Masters of Arts in Communicative Disorders from California State University, Long Beach. She holds the Certificate of Clinical Competence awarded by the American Speech-Language-Hearing Association and is a licensed Speech-Language Pathologist in the state of Texas (No. 104468). Michele is a member of both the Texas Speech-Language-Hearing Association and the American Speech-Language-Hearing Association. She is a certified provider of the Hanen parent program, “It Takes Two To Talk” and “More Than Words”.
rev. Feb. 2012 Client Services Contract