Informed Consent for REACH Therapeutic Intervention Services

YOUR NAME *
YOUR NAME
your first and last name
YOUR CHILD'S NAME *
YOUR CHILD'S NAME
your child's first and last name
REACH provides the following services: 1. Therapeutic intervention in the following: READING (decoding, fluency, comprehension); WRITING (constructing strong sentences, paragraphs, essays, reports, and narratives); SOCIAL-EMOTIONAL & BEHAVIORAL SKILLS (aggression, self-regulation, impulse control, self-image, coping skills); and ORGANIZATIONAL SKILLS (through coaching). 2. Consultations for the following: FAMILIES (how to support a child, adult support for dealing with struggles and frustrations). 3. Program planning for the following: PRIVATE CONSULTATIONS (working with other private consultants to help a child make progress); and SCHOOL CONSULTATIONS (school-based consultations regarding joining IEP teams, consulting with teachers and teacher teams, reviewing IEPs and reports, consulting on general IDEA and evaluation practices). 4. eClasses: These are one-hour classes on a variety of topics including but not limited to: understanding  special education and the evaluation process, how to support a child with ADHD, how to support reading at home, understanding common disabilities, and more. Participants have the option to (1) choose a live session where they can ask questions and receive 15  minutes of one-on-one coaching (scheduled after the session) ($39.95/class) or (2) download a class to watch at the participant's convenience ($19.95/class).
Informed consent must be obtained before consultation or report-writing services will be rendered.  For myself and/or for my minor child (hereafter referred to as "client"), I hereby agree to engage in online therapeutic intervention with a REACH education consultant. I understand that online therapeutic intervention may include consultation, treatment, and education using interactive audio, video, or data communications, including the recording of the session. I understand that online therapeutic intervention is not the diagnosis of a disability. The sole purpose of therapeutic intervention is to improve child outcomes, not diagnose. Results can not be guaranteed. 
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: 1. The laws that protect the confidentiality of my information also apply to online therapeutic intervention. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential, with the exceptions specified in state and federal law.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that dissemination of personally identifiable images or information from the online therapeutic interaction shall not occur without my written consent.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that there are risks and consequences from online therapeutic intervention, including, but not limited to, the possibility, despite reasonable efforts on the part of the REACH educational consultant, that the transmission of personal information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my information could be accessed by unauthorized persons.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand online therapeutic intervention services are not exactly the same as services delivered in a physical space. They may be more effective in some ways and/or less effective in some ways, but I understand if the REACH educational consultant believes another form of therapeutic services is indicated, s/he will recommend that.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that it is my responsibility to assure my video and audio signals and internet connectivity are adequate for intervention.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that, while the individualized online therapeutic intervention will be designed with the guidance of current “best practices” to improve language-literacy, social-emotional, or behavioral skills, but that results cannot be guaranteed or assured.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that I have a right to access my information and copies of records in accordance with the laws of the state in which I reside.
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: With regard to online therapeutic intervention sessions, I understand that: • It is my responsibility to meet the REACH educational consultant at the appointed time. • A 24 hours notice is required for all schedule change requests and that all schedule change requests are subject to the REACH educational consultant’s  availability. • Schedule changes that occur less than 24 hours before the session’s scheduled time will result in a $25 rescheduling fee.  • In the case of an emergency that does not permit a 24-hour notice, the REACH educational consultant will attempt to accommodate a make-up session within the  5 weeks but this cannot be guaranteed. 
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: I understand that consultation and other services are beyond the scope of therapeutic intervention. These services are available for additional fees.  • Family consultation: $55.00 per 1 hour. Billed in 15-minute increments.  • School-based consultations: $75 per hour. Billed in 1 hour increments.  • Reports writing: report writing is billed at the same hourly interval as school-
based consultations. Reports typically take 1.5 hours to write. 
I understand that I have the following rights and responsibilities with respect to online therapeutic intervention: In regard to payment, I agree to the following: • I will receive an invoice monthly. The invoice is reflective of upcoming sessions for the month. Sessions cost $295.00 for 4 sessions. This includes 30mins of  planned and follow-up for each session. I will have up to 5 weeks to use the 4 sessions. • It is my responsibility to ensure my account has sufficient funds and that I’m paying for sessions. • I understand that additional sessions will not take place until payment has been received. • I understand that there will be a $25.00 rescheduling fee if a session in canceled less than 24 hours before the scheduled session.
Please type your first and last name below, indicating your electronic signature.
Date *
Date
This indicates the date when you signed and submitted this form. This date goes along with your electronic signature to indicate your informed consent.