1661 Tice Valley Boulevard

Walnut Creek, CA, 94595

(925) 988-0648

For Kids

Your Custom Text Here

Once you have scheduled an evaluation, please fill out the following forms prior to your initial appointment.

Consent Form

Child's Name

First Name

Last Name

Date of Birth

YYYY

Parent's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Referred By

Emergency Contact

Contact Name

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

Allergy Information

ALLERGY ALERT/DIETARY RESTRCTIONS

Alergies

This child has the following allergies and/or food restrictions

Consent for Treatment

CONSENT FOR TREATMENT and RELEASE & EXCHANGE OF INFORMATION

School

Medical Doctor

Psychologist/Educational Therapist

Speech Therapist/Physical Therapist

Other

Payment Agreement

I have read and understand the attached letter stating policies of practice, including the cancellation policy. A cancellation after 8:00 AM the day of treatment will be charged at the full treatment rate. If your treatment time is before 10:00 AM, please call by 5:00 PM the previous business day to avoid being charged. I agree to pay PlaySpace Therapy the full amount of any and all fees related to services rendered. Payment is expected at the time of service. I understand that if I am seeking reimbursement from my health insurance company, I must file a claim for benefits independently.

I agree to the payment terms as outlined above.