- All health information is kept safe, as required by law. I acknowledge that I have read The Center for LifeSkills/Stefanie Peck Notice of Privacy Practices sheet. I may request a copy at any time.
Please notify your therapist of any vacations/scheduled medical appointments/school functions, etc., so that make-up sessions may be scheduled. We appreciate advance notice of these cancellations, as we can use those time slots for other make-up sessions or meetings.
- I understand that my child must be present at 75% of his/her regularly scheduled sessions, in any rolling 3-month period. If the attendance percentage drops below 75%, the regularly scheduled time slot may be forfeited.
- I understand that there will be a $45 charge if a session is missed without notification. I must notify my therapist about a cancellation at least 8 hours in advance of the scheduled appointment to avoid the $45 charge. I understand that this fee cannot be paid for by a third-party payor and will be my responsibility.
I give permission for my child to participate in photos and videos for media purposes for The Center for LifeSkills/Stefanie Peck. My child’s first name, photo and/or videos may be used and seen in printed marketing materials, website content, and/or our Facebook business page. Media will not be shared with any third parties. This release will remain active until I or my child's guardian notifies The Center for LifeSkills/Stefanie Peck.
Consent to Treat
I have read the above policies and agree to the terms. I consent to treatment for my child(ren), fill up form at the bottom by Brenda Richards, Stefanie Peck, or other therapists/student clinicians working in this office. I give permission for the therapist to accompany my child into the bathroom, if necessary.
Date Format: MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.