Consent Authorization Form - Adults - SPOT Children's Therapy Centre

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您的詳細信息

Your name*

电邮*

Your Date of Birth*

I hereby consent to receiving therapy intervention at SPOT as deemed appropriate by the therapist team.*

是的
不

我承認並同意取消政策*

包括我必須提前 24 小時通知治療師，或者如果需要取消，提供醫生證明，否則我將被收取全額預約費用（請查看我們網站上的完整取消政策).

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不

I understand that SPOT therapists participate in regular confidential clinical supervision in order to support best practice and continuing professional development. I understand that my case may be presented in supervision within the bounds of confidentially.*

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不

SPOT Centre Ltd 使用懸掛設備進行移動、攀爬和平衡，為兒童提供有益的治療體驗。 SPOT 治療師始終竭盡全力以將風險降至最低。與任何室內遊樂場一樣，儘管使用了墊子、襯墊、地墊並有成人監督，使用遊樂場和健身器材總是存在風險。風險最小化的一個重要部分是確保始終告知孩子的治療師任何健康、藥物或家庭狀況的變化，尤其是那些可能影響反應時間和運動控制的變化。

I have fully read the above statements and understand the inherent risks involved during activities using the SPOT equipment. I hereby release SPOT Centre Ltd owners and employees from any liability, claims, demands and causes of action, nor or in the future, resulting from soreness or injury however caused, occurring during or after my participation in therapy.*

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不

I would like to receive the monthly e-newsletter from SPOT.*

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不

I authorise SPOT therapists to photograph/video me for the sole purpose of keeping clinical records.*

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不

I authorise SPOT therapists to liaise with other professionals who are also involved in my therapy and learning. (Please list below)*

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不

其他治療師

請記下其他治療師和教育者的姓名和聯絡方式：*

姓名	聯絡資訊

簽名

簽名*

請使用滑鼠或手指在觸控螢幕裝置上在框內簽名。

姓名

此欄位用作驗證填寫的資料是否正確，請勿修改。

Consent Authorization Form – Adults

您的詳細信息

其他治療師

簽名

预约

SPOT 中心

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