Pediatric Occupational, Massage/Touch, Physical and Speech ...€¦ · Documentation of Consent for Pediatric Massage Therapy . I, (Print Name) _____, spoke to the parent/guardian

Private Massage Consent Form

Massage therapy for a child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include:

Skeletal Digestive Respiratory

• Aids in supporting good posture andbalance

• Reduces muscle tension that could leadto potential medical problems

• Increases nutrient flow to bones

• May relieve constipation• May relieve gas• May reduce water

retention• May improve GI function

• Improves breathingpatterns

• Helps reduce respiratoryproblems

• Relieves tension in thechest allowing the lungs toexpand more fully

Muscular Circulatory Nervous

• Relieves muscle tension and spasm• Aids in removal of lactic acid & carbonic

acid• Increases the flow of blood and nutrients

to muscles• Can increase or decrease muscle tone

depending upon amount of pressure• May decrease aversion to tactile

stimulation

• Stimulates blood andlymph circulation

• Helps strengthen theimmune system

• Releases toxins held inthe body

• Relaxes and calms• Improves sleep patterns• Raises endorphin levels,

promoting healing• Provides a safe and easy

release from frustrationand hyperactive behavior

• The Vagus Nerve isstimulated influencing foodabsorption hormones(Insulin & Glycogen) &attentiveness

Contradictions for Pediatric Massage Include

• Fever/Temperature • Acute infection, staph infection, illness or disease• Life threatening medical condition • Unhealed umbilical cord (tummy massage contraindicated)• Swollen lymph nodes • Blood clots or a blood condition• Diarrhea or other sickness • Inflammation• H1gh Blood Pressure • Hernia• Osteoporosis • Varicose Veins• Broken Bones • Deep Vein Thrombosis• Pain • Lability• Thrombocytopenia • Recent immunization/vaccination (wait 48- 72 hours)• Skin disorder/condition which may be contagious or cause inflammation (fungus, rashes, herpes)

Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy

1350 Pennsylvania Avenue McDonough, GA 30253 Page -1-

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www.HeartsAndHandsTherapy.com

2001 Professional Pkwy Suite 220 Woodstock, GA 30188

Common Precautions for Pediatric Massage Include

• Apnea • Bradycardia • Tachycardia • Abdominal Distention• Gastrointestinal or Jejunostomy feeding tubes • Inflammations • Edema• Dysplasia • Hemophilia • Jaundice • Recent Surgery• HIV/AIDS • Tumors • Cancer • Seizure Disorders• Agitation • Impulsivity • Hydrocephalus

Child's Name: _______________________________________________ Birthdate: _______________________

Caregiver's Name: ____________________________________________

Address: ____________________________________________________

City: ________________________________________ State: _____________ Zip: _________

Phone: ______________________________________ Cell/Pager: ___________________

Email: _______________________________________________________

Referred By: __________________________________________________

In case of emergency.

My healthcare provider is: ________________________________________

Phone: ________________________

Please indicate any of the high-risk factors, complications that I should be aware of:

Is there other relevant information about the pregnancy, childbirth, about you or the child, that I should know?

I, _____________, understand that my child will be participating in pediatric massage therapy as a form of adjunct health care

I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child's healthcare providers release.

I understand that my child will receive pediatric massage therapy as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or another licensed provider.

I hereby release and hold harmless and defend the practitioner from any claims, liability, demands and causes of action from my and my child's participation in this therapy.

Signature: ___________________________ Date: ________ Print Name: ______________________________

Practitioner's Signature: ______________________ Date: _______ Print Name: __________________________



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Pediatric Client Intake Form

Child's Name ___________________________________________________________ Birthdate _____________Age ______

Street -____________________________________________ City _______________________ State ______ Zip __________

Parent Occupation/Employer _____________________________________________________________________________

Please mark your goals for your child's Pediatric Massage Program:

Provide Comfort

Reduce stress

Ease Depression

Reduce muscle hyper tonicity

Improve gastrointestinal functioning

Promote orientation of extremities toward midline

Improve pulmonary functions

Reduce lethargy

Promote growth for baby born prematurely/child

Improve attentiveness and responsiveness

Decrease hypersensitivity to touch

Enhance child's body awareness

Promote relaxation

Reduce pain

Decrease anxiety

Improve muscle tone (decrease hypo tonicity)

Improve joint mobility I range of motion

Reduce chronic fatigue

Decrease symptoms of atopic dermatitis

Reduce colic I chronic abdominal pain

Improve self-soothing behavior

Improve sleep patterns

Encourage vocalization

Promote parent-child bonding

Other Goals: ____________________________________________________________________________________________

Health History

Birth History: Biological Child Adopted Foster Child

Weeks’ gestation: _____ Delivery: Vaginal Forceps C-Section Vacuum Extraction

Postpartum complications? No Yes (describe): _______________________________________________________

Is your child currently under the care of a primary healthcare provider? Yes No

Name of healthcare provider: _____________________________________________________________________________

Name of healthcare facility: _______________________________________________________________________________

Location: _____________________________________________________________________ Phone: __________________

May I exchange information when necessary with this provider? Yes No



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My child is developing:

like an average child for his/her age in all areas of development

differently than an average child his/her age in any area of development.

Describe: ____________________________________________________________________________________

Please list medications, supplements or homeopathies the child is now taking:

Medication/Herb/etc. Reason Started Dosage

_____________________ ____________________________ ___________ ___________

_____________________ ____________________________ ___________ ___________

_____________________ ____________________________ ___________ ___________

_____________________ ____________________________ ___________ ___________

Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable

Now Past Now Past Condition

Respiratory Conditions (includes sinus, lung and bronchial conditions. etc.) Type_________________________________ Location ______________________________

Circulatory Conditions(Includes heart. blood pressure, arteries and venous conditions. etc.) Type__________________________________ Location ______________________________

Reproductive Conditions(includes pregnancy, prostate, menstruation) Type__________________________________ Location ______________________________

Digestive Conditions(includes constipation, diarrhea, ulcers) Type__________________________________ Location ______________________________

Condition

Skin Conditions(includes rashes. topical allergies, fungal Infections. etc.) Type__________________________________ Location ______________________________

Muscle Conditions(Includes strains, tendonitis. spasms, cramps) Type_________________________________ Location ______________________________

Joint Conditions(Includes sprain, arthritis, degenerating joints) Type_________________________________ Location ______________________________

Nervous System Conditions(Includes numbness. tingling, nerve damage, shingles, etc.) Type_________________________________ Location ______________________________

Infectious or Communicable ConditionsType_________________________________ Location ______________________________

Other Conditions(Includes any other health condition not previously listed) Type_________________________________ Location ______________________________



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Other medical conditions, symptoms and/or further explanations

Please list any recent accidents, illnesses or surgeries (past 2 years --or those that are still affecting your child

Please list any special dietary/nutritional considerations: (i.e.: gluten-free diet, allergies)

How do these symptoms affect the child's daily life?

Therapeutic History

Has your child ever received massage or another bodywork therapy (professionally or by a parent's touch)? (example: yoga therapy, cranial sacral therapy, bio aquatic therapy) Yes No If yes, please explain:

Please list other complementary therapies or educational programs in which your child participates:

Therapy/Program Reason Started Practitioner

_________________________________ _______________________ __________ ____________________

_________________________________ _______________________ __________ ____________________

_________________________________ _______________________ __________ ____________________

_________________________________ _______________________ __________ ____________________

May I exchange information when necessary with these providers? Yes No Has your child been evaluated for or diagnosed with Sensory Integration Disorder? Yes No If yes, please explain evaluation, diagnosis and/or therapy program: __________________________________________________________________________________________________________



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Never Some Often Always In the past This is a Problem

Seem irritated when touched?

Bang or hit head on purpose?

Seem overly aware of touch. texture or temperature?

Have an increased response to pain?

Lack awareness of being touched?

Bite. chew or suck on blanket/pacifier/something to calm

Frequently bump into or push people or items?

Have a strong need to touch objects and people?

Try to bite people?

Dislike being bounced, rocked or swung?

Seek out rough-housing play?

Have fear in space (i.e. on stairs, heights. etc. )?

Dislike being off balance?

Personal History

Please describe your child's communication style: Verbal Word Approximations ASL PECS Augmentative Device Gestures None Other:______________________________________________________________________________

How does your child deal with change? ____________________________________________________________________________________

What types of methods does your child use to manage stressful situations (self-soothing techniques)? _____________________________________________________________________________________ ______________________________________________________________________________________

How do you deal with it? What makes your child:

Happy ?

Sad ?

Angry ?

Stressed ?

Excited ?

Dislike being held or cuddled



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Does your child attend school/preschool/daycare? Yes No

If yes, what are his/her teacher's name(s)? _____________________________________________________________________

What are the names/types of his/her pets? ____________________________________________________________________

What are the names of his/her siblings? ______________________________________________________________________

What are the names of his/her friends? ______________________________________________________________________

What types of exercise interests your child? ____________________________________________________________________

How does your child prefer to spend his/her time (hobbies/interests)? ______________________________________________

I have listed all my child's known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that my child has in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder. nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my child may have.

I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being

charged.

Signed ______________________________________________________________Date ________________

Parent/Legal Guardian of ___________________________________________________________________



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Documentation of Consent for Pediatric Massage Therapy

I, (Print Name) ______________________________________, spoke to the parent/guardian of ____________________________ ( in person/ on the phone) about Pediatric Massage Therapy. I informed them that this is treatment has been cleared by the child's physician.

I discussed risks and benefits of massage. Benefits include relaxation, pain relief and comfort. Risks include allergy to massage oil/lotion(list type) ___________________________________________ , emotional release related to relaxation, and musculoskeletal soreness.

Opportunity was given for them to ask any questions and these questions were answered.

Questions asked:

Was the use of an interpreter required? Yes No

The parent/guardian stated understanding of this intervention and gave permission for Massage.

Signatures

Person obtaining consent: _______________________________________

Interpreter: _______________________________________

Date/time: ______________________

Parent/guardian: ______________________

Witness: ______________________

Date/Time: ______________________



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Appointment Times

Preferred Appointment Times/Schedule

Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7 a.m to 8 a.m. 8 a.m to 9 a.m. 9 a.m to 10 a.m. 10 a.m to 11 a.m. 11 a.m to 12 p.m. 12 p.m to 1 p.m. 1 p.m to 2 p.m. 2 p.m to 3 p.m. 3 p.m to 4 p.m. 4 p.m to 5 p.m. 5 p.m to 6 p.m.

Cannot attend Times (Please specify which days/time you absolutely cannot attend, we will make an effort to use your preferred times above, and will not schedule you for the lists times below.)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7 a.m to 8 a.m. 8 a.m to 9 a.m. 9 a.m to 10 a.m. 10 a.m to 11 a.m. 11 a.m to 12 p.m. 12 p.m to 1 p.m. 1 p.m to 2 p.m. 2 p.m to 3 p.m. 3 p.m to 4 p.m. 4 p.m to 5 p.m. 5 p.m to 6 p.m.

Additional information regarding scheduling of your appointments.


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CANCELLATION AND NO SHOW POLICY

CANCELLATION POLICY Your child’s therapy is very important, and Hearts and Hands Therapy Services wants to provide the most effective services to all clients. We are committed to helping improve your child’s overall development; however, your child’s therapy will not progress if too many sessions are missed.

We understand that sometimes a session must be canceled due to illness or other conflicts, but we ask that you give your therapist a 24-HOUR CANCELLATION NOTICE.

If you need to cancel your child’s appointment on the same day as the therapy, please call your child’s therapist as soon as possible. If you are not able to reach him/her, please leave a message on their phone and call the office so that we can try to notify them as well. If therapy is cancelled less than 24 hours in advance, you will be charged a no-show fee of $30 for the missed session.

NO SHOW POLICY If you do not cancel your child’s appointment, it is considered a “No Show”.

The HHTS policy states that a client may be discharged from therapy or placed on a waiting list if there have been more than 2 “No Shows”.

It is your responsibility to contact your therapist if you must cancel the therapy session or have a problem with your child’s appointment.

Child’s Name: _______________ Parent/ Guardian Signature: __________________Date: ____________

Hearts and Hands Therapy Services Inc. Pediatric Occupational, Physical and Speech Therapy


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Photo Consent Form I, _______________________, AUTHORIZE the use of photographs of my child,______________________, for any forms of media advertising for Hearts and Hands Therapy Services, Inc. Types of media include videos, websites, magazines, photographs, flyers, or other similar publications.

Parent/ Guardian Signature: _____________________________________________Date: ____________

Or I, ______________________, DO NOT AUTHORIZE the use of photographs of my child, ___________________, for any forms of media advertising for Hearts and Hands Therapy Services, Inc. Types of media include videos, websites, photographs, flyers, or other similar publications.

Parent/Guardian Signature: ________________________Date: ____________

Privacy Practices and Procedures Acknowledgement Form I, ____________________________, (client, or guardian if under 18) understand that Hearts and Hands Therapy Services, Inc. may be provided access to, or create on my behalf, certain protected, identifiable, health information and that I have certain rights to the restriction of disclosure and use of such information. I hereby, acknowledge that on the ___ day of, ________ , ______

I was presented with a copy of Hearts and Hands Therapy Services, Inc.’s HIPA Notice of Privacy Practices pursuant to HIPA and 45 C.F.R. Parts 260 and 164 and applicable state law. I have reviewed the Notice and understand its terms or have been provided an opportunity to have the same explained to me.

Parent/ Guardian Signature: _______________________________________________________________



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Credit Card on File Agreement

We have implemented a new policy, which requires all Hearts and Hands Therapy Services (HHTS) clients to keep a credit card on file for payment purposes. Our system enables us to maintain your credit card information securely on file and which can only be accessed under the terms specified below. By providing us with your credit card information you are giving HHTS permission to automatically charge your credit card if payment is not made by you within 30 days of your invoice. Please note there is a 5% fee after your invoice is over 30 days old. The billed amounts will match the patient responsibility amount as determined by your insurance. There are no co-pays or fees for services if you have Medicaid or Deeming Waiver Medicaid as primary or secondary insurance. In the event of loss of Medicaid you agree to notify HHTS immediately. Failure to do so will result in potential charges to you at the Medicaid Rate.

Any missed appointment without cancellation will result in the credit card on file being charged the no show fee of $30.00.

If the credit card information we have on file changes for any reason, you must notify HHTS as soon as possible. If you have any questions about a charge, please notify us within 15 days. After 30 days all charges will be assumed to be correct. We will maintain a clear record of all payments and charges. However, in the result that an overpayment occurs your account will be credited on the upcoming invoice or if the balance is zero a reimbursement can be put back on the same credit card or a check can be mailed directly to you. A receipt will be sent to you from our credit card processing company. In the event of a declined charge you will be asked for a new credit card number and or payment before continuing therapy services.

I HAVE READ AND UNDERSTAND THE CREDIT CARD ON FILE AGREEMENT AND AUTHORIZE HHTS TO CHARGE MY CREDIT CARD AS ABOVE STATED ABOVE

Child’s Name:__________________________________________________________________________

Please select one of the following Visa MasterCard American Express Discover

Name on Credit Card: ____________________________________________________________________

Billing Address:_________________________________________________________________________

City: _______________________State_________________ Zip code: __________

Credit Card Number: _____________________________Exp. Date: ___________ Security Code: _______

_____ Initial here if you would like all invoices including new invoices to be billed to above credit card.

Please check one Weekly Monthly

Signature: _________________________________________________Date: _________________



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HIPPA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1) Hearts and Hands Therapy Services, Inc., hereinafter Hearts and Hands, is permitted to make use ofand to disclose health care information for the purposes of treatment, payment and health careoperations. The following are examples of use or disclosure for each of the listed purposes:A. Example of use or disclosure for the purpose of treatment: Private health information may be

disclosed to gain knowledge about our diagnosis or prognosis to help us treat your conditionappropriately.

B. Example of use or disclosure for the purpose of payment: Private health information may bedisclosed so that we may collect payment from your insurance company or other healthcarecoverage.

C. Example of use or disclosure for the purpose of health care operations: Hearts and Hands maycontact the individual to provide appointment r e m i n d e r s , in f or ma t i on a b o u t yourtreatment a l ternat ives o r other health related benefits services that may be of interest to theindividual.

2) Hearts and Hands is permitted or required to use or disclose protected health informationwit hout the individuals wr i t ten authorization for the following purposes:A. To maintain a directory of individuals.B. To a family member, other relative or a close friend of the individual, or any other person identified

by the individual, to the extent disclosure is directly relevant to the individual’s care or paymentrelated to the individual’s care.

C. To notify a family member, a personal representative of the individual or another personresponsible for the care of an individual of the individual’s location, general condition or death.

D. Where necessary, to assist a public or private entity authorized by law or by its charter, in disasterrelief efforts. E. Where the disclosure or use is required by law.

E. To assist the public health authority that is authorized by law to collect or receive such informationfor the purpose of

F. preventing or controlling disease, injury or disability.G. To assist a public health authority or other appropriate government authority authorized by law

to receive reports of child abuse or neglect.H. To provide information regarding a person subject to the jurisdiction of the Food and Drug

Administration with respect of an FDA regulated product or activity for which that person hasresponsibility.

I. Where authorized by law to notify an individual, who may have been exposed to a communicabledisease or may otherwise by a risk of contracting or spreading a disease or condition.

J. To an employer to conduct an evaluation relating to medical surveillance in the workp l a c e orevaluate whether the individual has suffered a work-related illness or injury and where evaluationnotice of such disclosure is given to the individual.



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K. Where made to a government authority about an individual reasonable believed to be the victimof abuse or neglect.

L. To a health oversight agency for oversight activities authorized by law.M. Pursuant to a court order or properly restricted subpoena upon notice.N. To a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material

witness or missing person.O. To a law enforcement official for the purpose of identifying who is or is suspected to be the victim

of a crime.P. To a law enforcement official regarding a death if there is reason to believe the death resulted from

criminal conduct.Q. To law enforcement official if the information constitutes evidence that a crime has occurred on

Hearts and Hands premises.R. To a law enforcement officer in response to a medical emergency, if necessary, to alert such

officer to aspects of a crime.S. To a coroner of medical examiner for the purpose of identifying a deceased person, determining

the cause of death, or other duties as authorized by law.T. To funeral directors consistent with applicable law to carry out their duties with respect to the

decedent.U. To organ procurement o r g a n i z a t i on s e n g a g e d in the procurement, b a n k i n g or

transplantation o f organs, eyes or tissue.V. To assist, where necessary, for research purposes where adequate restrictions are in place.W. Where necessary to prevent or lessen a serious and imminent threat to the health or safety of

the person or the public.X. Where the individual is Armed Forces personnel and the information is deemed necessary by

military command authorities to assure proper execution of military mission.Y. Where the individual i s foreign mi l i tary personnel a n d the information i s deemed

n e ce s sa r y b y foreign Military command authorities to assure proper execution of the militarymission.

Z. To authorized federal officials to conduct lawful intelligence gathering, counterintelligence, and othernational security activities authorized by the National Security Act.

AA. To authorized federal officers for the provision of protective services to the President. BB. To correctional institutions or authorized law enforcement officers for the provision of care of

inmates and the safety and administration of the correctional facility. CC. To the extent necessary to comply with law relating to workers’ compensation or other similar

programs and:DD. Any other permitted purposes define in 45 C.F.R. Parts 160 and 164.



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3) Other uses and disclosures of information wil l be made only with the individual’s writtenauthorization. The individual may revoke such authorization at any time provided that therevocation is in writing except to the extent that:A. Hearts and Hands has acted in reliance thereon, orB. If the authorization was provided as a condition to obtaining insurance coverage or the law

permits the insurer the right to contact regarding the claim under the policy itself.4) The individual retains the following rights with respect to protected information:

A. The right to request restrictions on certain uses and disclosures of protected health information.Hearts and Hands is not required to agree to a requested restriction.

B. The individual retains the right to receive confidential co mm u n ic at ion s o f protectedhealth information ab o u t the individual.

C. The individual retains the right to inspect and copy protected health information about theindividual except for the following:i) psychotherapy notesii) information c o m p i l e d in reasonable a n t i c i p at i o n o f , or for use in, a civil, criminal or

administrative a c t i o n or proceeding andiii) protected health information subject to the Clinical Laboratory Improvements Amendments

of 1988, to the extent the provision law or information would prohibit access to the individualexempt from the Clinical Laboratory Amendments of 1988.

D. The individual retains the right to amend protected health information so long as Hearts andHands retains such information. Hearts and Hands retains the right to deny an individual’srequest to amend protected health information if it determines:i) that the information to be amended was not created by Hearts and Hands, unless the

individual provides a reasonable basis to believe that the originator of the protected healthi n f o r m a t i o n is no longer available to act on the requested amendment:

ii) the information sought to be amended is not part of the designated set of the individual’srecord: Hearts and Hands determines that the record or information sought is accurate andcomplete.

E. The individual retains the right to receive an accounting of disclosures of protected healthinformation made within six (6) years prior to the date on which the accounting is requestedexcept for disclosures:i) Made to carry out treatment, payment and health care operations.ii) Made to an individual upon that individual’s request of protected health information about

that individual.iii) Made incident to a use or disclosure otherwise permitted or required by law.iv) Made pursuant to an authorization provided but not in the Notice.v) Made for the facility’s directory or to persons, such as an individual’s care or otherwise

entitled to notification.vi) Made for national security or intelligence purposes.vii) Made to correctional institutions or law enforcement official.



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viii) Made as part of a limited date set that does not contain identifying information regarding theindividual: or

ix) Made prior to the effective compliance date of Hearts and Hands original notice.F. The individual including any individuals who have agreed to receive the Notice electronically,

retain the right to obtain a copy of the Notice from Hearts and Hands upon request.G. Hearts and Hands is required by law to maintain the privacy of protected health information and

to provide individuals with notice of its legal duties and privacy practices with respect toprotected health information.

H. Hearts and Hands is required to abide by the terms of the Notice currently in effect.I. Hearts and Hands reserves the right to change the terms of its notice and to make the new

notice and provisions effective for all protected health information that it maintains. In theevent that Hearts and Hands seeks to apply a change in a privacy practice that is described inthe Notice to protect health information that Hearts and Hands created or received prior toissuing a revised notice, Hearts and Hands shall provide individuals with a revised notice byhandout or mail.

J. Individuals may complain to Hearts and Hands and to the Secretary of Health and HumanServices if they believe their Privacy rights have been violated. If an individual chooses to file acomplaint with Hearts and Hands, he/she may do so in the following manner: writtencomplaint/notice. The individual will not be retaliated against for filing a complaint.

K. If the individual desires further information co n cern in g h is/her privacy rights under thisNotice, they may contact

Hearts and Hands Therapy Services, Inc 1-844-543-8437

2001 Professional Pkwy, Woodstock, GA 30188.

L. This Notice first went into effect on the 1st Day of May 2008. This date is not earlier than thedate on which the Notice has been printed or otherwise published.



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Documents

Pediatric Occupational, Massage/Touch, Physical and Speech ...€¦ · Documentation of Consent for Pediatric Massage Therapy . I, (Print Name) _____, spoke to the parent/guardian