Valley Family Therapeutics, LLC (VF) Permission to Treat
TREATMENT OF MINORS: I, as parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
LIABILITY: I agree that (VF) is not responsible for loss or damage to personal valuables.
CANCELLATION POLICY: You are required to provide 24 hours notice to cancel an appointment. In the event you have 2 cancellations with less than 24 hours notice Valley Family Therapeutics will no longer be able to reserve that treatment time for your child and you will be moved to our waiting list. As a courtesy we do not charge a cancellation fee.
NO SHOW POLICY: If you are unable to keep a scheduled appointment, please let us know in advance. A NO SHOW occurs when you miss an appointment without canceling it in advance or you fail to be present at the time of a scheduled appointment. Two No Shows may require that you seek your treatment elsewhere. After the first No Show occurrence, your therapist will contact you to discuss the No Show and review our policy. The No Show will be documented in patient chart. After the second No Show occurrence, a letter will be sent to you alerting you regarding your failure to keep you scheduled appointment. Your child may be discharged from the practice.
In the event that you have a special circumstance regarding your missed appointment, please contact our Practice Manager at 484-863-9220. We understand that there may be issues beyond your control and want to be understanding of special circumstances.
If you are delayed and cannot make an appointment on time, please call to advise us of your situation and provide an estimated time of arrival. Any significant delay may require the visit to be rescheduled or waiting until the therapist next open appointment time.
HOLDING APPOINTMENT POLICY: Appointment times/days will be held fortwo weeks during in-attendance, regardless of cause. If unable to keep the allottedslot, the appointmentwill be released to serve the needs of the many patients on our waiting lists. Once services are able to be continued, the next available openingswill be offered to your child.
VFT thanks you for your understanding of these policies.
RELEASE OF MEDICAL INFORMATION: I hereby authorize the release of medical records that are necessary to facilitate my child’s treatment, inform (VF) staff of medical findings, and to process medical claims.
I Agree to the Posted HIPPA Form and all policies at our office.
Signature of Patient or Personal Representative
Printed Name of Patient or Personal Representative and his or her Relationship to Patient
Date signed