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Locus Family Centered Therapies

Locus Family Centered Therapies

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Intake Form For New Families


Parent/Guardian is Emergency Contact?
Communication Preference
Drop-down for mornings (8am-noon), after lunch (noon-3pm) & before dinner (3-6pm)
Location Preferred *

Other Therapies

Please note any other services your child receives
NC Infant-Toddler Program *Is your child enrolled in the NC-ITP?

Financial Responsibility

By completing this form, I am confirming that I am financially responsible for all verifiable account balances.


Financial Responsibility

Consent

Consent for Treatment:

Parent/guardian signature below provides consent for Company to provide occupational therapy evaluation and/or treatment as deemed necessary during care. I understand that treatment and recommendations are made based on necessary clinical judgment, and should additional referrals be needed or suggested, that I will be informed of those recommendations.

Patient Communication:

Parent/guardian signature provides consent for Company to communicate through secure email, text message, and phone call to communicate timely reminders and therapy updates as appropriate.

Release of Information:

Parent/guardian signature provides consent to Company to disclose or exchange any or all parts od medical records, such as medical history, evaluations, progress notes and treatment plans, with the child's last insurance company, primary care physician, Children's Developmental Services Agency, if applicable, and any additional listed provider, specialist, or caregiver as identified by the signing parent/guardian.

Display still photos on Company website and/or social media (first name only)

Use still photos in promotional materials

Use photos for documenting progress/ change in condition

Display videos on Company website and/or social media (first name only)

Use videos for documenting progress/ change in condition

Use videos for staff/fieldwork education and mentoring

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Mentoring staff is key
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