Unique Prints Pediatric Therapy Services, Inc. Parental Consent
for Occupational Therapy and Sensory Integration Treatment
Therapy may include treatment for: Sensory Processing Disorder, developmental delays, Cerebral Palsy, Down syndrome, chromosomal disorders, fine motor and gross motor issues, etc.
Potential risks and discomforts: Sensory integration is a powerful intervention technique for individuals who are experiencing a difference in how they process sensory information. It is not uncommon to experience an increase in emotionality as the nervous system is changing and reorganizing itself. A sensory integration (or occupational therapy) session often provides a variety of movement opportunities for the child including climbing, jumping, swinging and utilizing a variety of other therapeutic equipment. Your child’s therapist will do his/her best to protect your child; however, unforeseeable accidents may occur which could result in injury.
Potential benefits: When a sensory integrative approach to therapy is successful, the child is better able to automatically process complex sensory information. This can result in improved fine and gross motor coordination, and improved ability to self regulate inner states of arousal. These gains can lead to improved self-esteem, improved personal-social skills, and greater self-confidence.
Waiver of liability: On behalf of me and the named child and the child’s parents, and our heirs, successors, representatives and assigns, I hereby forever release and waive any and all claims, demands, losses and causes of action of any nature whatsoever, whether known or unknown, against Unique Prints Pediatric Therapy Services, Inc. and its employees, agents, directors, representatives, partners, consultants, instructors, volunteers, and staff pertaining to accidents, injuries, damages or losses suffered by me or my child(ren) arising from or caused in whole or in part by occupational therapy or sensory integration treatment whether arising before, during or after said treatment.
Consent for treatment:
After receiving information concerning the therapy and treatment, I freely and voluntarily give my permission to have ______participate in pediatric occupational therapy which may
(patient’s first and last name)
include sensory integration treatment.
I represent to Unique Prints Pediatric Therapy Services, Inc. that I am legally authorized to sign this consent, waiver and release on behalf of the named child.
______
First and Last Name of Patient (child)
______
Name of Authorized Representative
______
Signature of Authorized Representative Date