Let's get sessions started

I am the parent or legal guardian of the child named in this intake. I request and consent to occupational therapy screening, evaluation, and treatment of my child by Jenna Maurer, OTD, OTR/L, of Jenna Maurer OTD Services.

I understand that: occupational therapy for children is active and play-based; an evaluation will be completed and goals reviewed with me; I may ask questions about, decline, or discontinue any part of evaluation or treatment at any time; results and progress vary by child and no specific outcome is guaranteed; and therapy may occur at my child's school, in my home, or another agreed setting, including when I am not present.

This consent remains in effect until I revoke it in writing or services end.

Your child's information belongs to your family. This notice explains what we collect, how we protect it, when we share it, and your rights.

What we collect. Contact and household information you provide; your child's health, developmental, and educational information relevant to occupational therapy; screening and evaluation results, session notes, and progress records; billing and payment records.

How we protect it. Records are stored securely with access limited to the treating therapist. Electronic records are encrypted. We do not sell information or share it for marketing.

When we share it. Only: (1) with people or providers you have authorized in writing — for example, your child's teacher, pediatrician, or other therapists; (2) for payment purposes you have chosen — for example, providing documentation to Step Up For Students/EMA for scholarship billing, or giving you a superbill you may submit to your insurer; (3) when the law requires it, including suspected abuse or neglect (Florida law makes therapists mandatory reporters), court orders, and situations involving serious threat of harm; (4) in a medical emergency involving your child.

Your rights. You may see and receive a copy of your child's records; request corrections; withdraw any authorization to share information going forward, in writing, at any time; and receive an accounting of disclosures made outside your authorization. Requests go to [PRACTICE EMAIL].

Retention. Records are kept for at least [RETENTION PERIOD] and are then securely destroyed.

Questions or concerns: contact Jenna Maurer at [PRACTICE EMAIL] or [PRACTICE PHONE]. If you believe your privacy rights have been violated, you may also contact the Florida Department of Health.

I authorize Jenna Maurer OTD Services to share and receive information about my child's occupational therapy — including evaluation results, goals, progress, and recommendations — with the people and providers I have listed in my intake form (for example: my child's teacher and school, pediatrician, and other treating therapists), for the purpose of coordinating my child's care and education.

This authorization does not permit sharing for any other purpose. I may revoke it in writing at any time, effective going forward. It expires [one year from signing / when services end] unless renewed.

I consent to Jenna Maurer OTD Services communicating with me by email and text message at the addresses and numbers I provided, regarding scheduling, billing, forms, home programs, and information related to my child's services. I understand that standard email and text are not fully secure, that I can request an alternative method for any communication, and that I may revoke this consent in writing at any time.

Short photo or video clips may be taken during sessions solely to document progress and to show families home-program activities. They are stored securely with the treatment record, are not used for marketing or social media, and are not shared beyond the people authorized in the coordination-of-care authorization without separate written permission. Consent is optional; declining does not affect care in any way, and consent may be revoked in writing at any time.

Occupational therapy for children is physical by design: climbing, swinging, jumping, balance work, tools, and messy play. Trained supervision and appropriate equipment reduce risk but cannot eliminate it; minor injuries such as bumps, scrapes, and falls are possible, as they are in any active play.

In consideration of services provided to my child, I acknowledge and accept the inherent risks of these activities. To the fullest extent permitted by Florida law, I release and agree to hold harmless Jenna Maurer, OTD, OTR/L, and Jenna Maurer OTD Services from claims arising from the ordinary risks of my child's participation in therapy activities. This release does not apply to gross negligence or intentional misconduct.

In a medical emergency during a session when I cannot be reached, I authorize the therapist to call 911 and to arrange transport of my child to the nearest appropriate medical facility, and to share with responders the information needed for my child's care. I remain responsible for any medical costs.

Sessions. Treatment sessions are [50] minutes unless otherwise arranged, at your child's school, in your home, or [OTHER LOCATIONS], as agreed.

Cancellations. Life with small children is unpredictable — we plan for that.

• Illness is always excused. If your child has had fever, vomiting, diarrhea, or new illness symptoms within the past 24 hours, please cancel and we will reschedule without charge. Please do not send a sick child to session; the therapist moves between families and schools.
• Other cancellations need at least 12 hours' notice. With notice, no charge. With less, or a missed session without notice, the session fee of [$AMOUNT] may be charged. The first late cancellation each [quarter] is waived as a courtesy.
• School-schedule conflicts (assemblies, field trips, early dismissal) are excused; where possible we will reschedule the same week.
• If attendance becomes a pattern, we will talk about whether the schedule, setting, or timing needs to change.

Payment. Step Up (EMA direct pay): reserve funds in EMA before each period of service; sessions are invoiced to EMA at no cost to you. Private pay: due at time of service by [PAYMENT METHODS]. Insurance: we do not bill insurance; on request you'll receive a superbill you may submit for out-of-network reimbursement. Scholarship reimbursement: receipts with required documentation are provided; the claim is between you and Step Up. Accounts more than [30] days past due may pause services until current.

Ending services. Either the family or the practice may end services with one week's notice by phone or email. Records and a transition summary are available on request.