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Consent to Treat

Version 1.0Effective: February 10, 2026Last Updated: February 10, 2026

This document requires your signature

By signing below, you consent to evaluation and treatment of your child by the therapist named in your booking. This consent is required before any session can take place.

1. Purpose of This Form

This Consent to Treat authorizes a licensed therapist listed on ViaThera to evaluate and treat the child named in your booking (referred to as "your child").

You must be the parent or legal guardian of the child to sign this consent.

2. Nature of Services

Therapy services may include but are not limited to:

Occupational Therapy (OT): Evaluation and treatment of fine motor skills, sensory processing, self-care skills, handwriting, feeding, and daily living activities.

Physical Therapy (PT): Evaluation and treatment of gross motor skills, balance, coordination, gait, strength, and physical mobility.

Speech-Language Pathology (SLP): Evaluation and treatment of speech, language, communication, voice, fluency, and feeding and swallowing disorders.

3. Risks & Benefits

Benefits of therapy may include improved functional skills, developmental progress, increased independence, and enhanced quality of life.

Risks are generally minimal but may include temporary fatigue, frustration, or sensory discomfort during treatment activities. The therapist will take reasonable precautions to minimize any discomfort.

4. Independent Contractor Acknowledgment

I understand and acknowledge that:

  • The therapist is an independent contractor, not an employee of ViaThera
  • ViaThera provides a technology platform only
  • Clinical decisions are made solely by the licensed therapist
  • ViaThera is not responsible for clinical outcomes or therapy results

5. Insurance & Payment

I understand that:

  • ViaThera does not accept insurance
  • All services are private pay
  • Session fees are due before each session
  • A superbill may be requested for potential out-of-network insurance reimbursement
  • Reimbursement is not guaranteed

6. Photography & Recording

The therapist may not photograph or record your child without separate written consent. Session notes and progress documentation do not require additional consent.

7. Cancellation

I understand ViaThera's cancellation policy:

  • Free cancellation up to 24 hours before session
  • Late cancellations may incur the full session fee
  • Repeated no-shows may result in booking restrictions on my account

8. Right to Withdraw Consent

I understand I may withdraw this consent at any time by notifying the therapist or ViaThera. Withdrawal does not affect any sessions already completed or in progress.

9. Emergency Procedures

In the event of a medical emergency during an in-home session, the therapist is authorized to call 911 and administer basic first aid. The therapist will immediately notify the parent/guardian.

Sign Consent to Treat

This electronic signature has the same legal effect as a handwritten signature.

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