Think Again Speak Again Therapy

of MadeQuest Services Corp. Consent, Release, and Acknowledgement

1) I consent to receive mental health and/or speech-language pathology services.

2) I agree to assist in providing complete and comprehensive health information and have supplied up to date records necessary to provide informed quality services outside of a ‘vacuum.’ I consent to release medical records as needed and to continue informing the therapist provider (hereby referred to as ‘provider) in case medical changes are made and as updates occur.

3) For speech-language services, I verify that I have and have supplied a current doctor’s order to receive evaluation and/or treatment. I am aware of the need and agree to update the provider in case of any changes to physicians’ orders, recommendations, procedures, related care, and/or insurance.

4) I am aware that updates will be sent primarily via secure email. No recording, reproduction, modifications, use, and/or licensing of consultation, assessment, and/or therapy content allowed.

5) I am aware of my duty to pay my insurance company’s, if applicable, family cost participation and agree to maintain a zero balance at date of service.

7) I consent to notify the provider of need to cancel sessions at least 24 hours prior to scheduled service, particularly if I am sick and/or recovering to prevent cross contamination and cancellation fee. No refunds for no call/no shows, for the entire hour is reserved for each patient and provider preps for each appointment with individualized detail.

8) I am aware that repeated failure to cancel with prior notice, (not including/to be differentiated from cancellations), constitutes allowance of withdrawal of provider from applicable Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP), and/or plan of care (POC).

9) If applicable, I consent permission to bill my insurance company for services rendered.

10) I understand that the number of visits indicated on Plan of Care (POC), the Individualized Service Plan (IFSP), and/or Individualized Education Plan (IEP) is a fluid number, which may be adjusted, dependent upon the performance and needs of the patient.

11) I will consult my provider as the first line of communication to address my questions and/or concerns regarding patient’s Plan of Care.

12) I hereby attest that the information furnished by me to the provider is true and complete to the best of my knowledge and is furnished in good faith. I fully understand that any significant misstatement in, or omission from information provided could significantly impact relevance and effectiveness of services provided and/or constitute interruption, and/or discontinuation of services. I release from liability any persons or entities that provide information and/or services in furtherance, to the fullest extent allowed by applicable statutes and regulations and am bound by the terms of this contract, which survive beyond discontinuation of services.

13) In the event of an emergency, dial 911. You may reach your therapist via email at therapy@madequest.com in between sessions and via mobile chat for more urgent responses.

14) Session content is completely confidential with the exception that providers may disclose private information without consent in order to protect the patient or the public from serious harm, for example, a client discusses plans to attempt suicide or harm another person, are required to report ongoing domestic violence, abuse or neglect of children, the elderly or people with disabilities, and release information if a court order is received.