CONSENT AND SERVICE AGREEMENT
Welcome to Home Run Pediatric Occupational Therapy! This service agreement provides you with a summary of fees and essential information that will assist in providing the best possible care for your child.
Occupational Therapy Fees
Service and fee schedule:
Initial Assessment (Intake, 2 sessions, debrief) – $380.00
Therapy session (45 mins) – $120.00
Therapy session (60 mins) – $140.00
Professional Consultation (30 mins) – $75.00
Report – $350.00
Letter – $75.00
Travel fees – Location dependent and may/may not apply to your visit. TBD in advance of booking.
Please note the following:
Clients are responsible for payment of service, and will receive an electronic invoice through QuickBooks.
A minimum of 24 hours notice is required to cancel or reschedule an appointment, which may be done by phone or SMS to 613-315-9919. If less than 24 hours notice is given, there will be a 50% charge of the session fee, pending circumstances such as contagious illness, lice or positive COVID screening.
Home Run does not direct bill or submit claims to insurance providers. Clients will be provided with a receipt of services rendered.
Use and Disclosure of Personal Health Information
Please note the following:
Health information will be kept confidential and in compliance with the Personal Health Information Protection Act (PHIPA), Personal Information Protection and Electronic Documents Act, and the College of Occupational Therapists of Ontario.
Health information is collected in person, by email, or by phone.
Your Health Information will not be shared with third parties without your prior consent.
Mandatory Reporting
Please note the following:
Health professionals, including Occupational Therapists, are legally obligated to report any known or reasonably suspected incidents of abuse or neglect to the Children’s Aid Society.
Consent for Occupational Therapy Services
Please note the following:
Occupational Therapy Services may include collection of health information and developmental history, assessment of the child’s functional abilities (within Occupational Therapy scope of practice), use of formal and informal methods of information collection including clinical observation and/or standardized assessments, direct intervention, consultation and/or documentation.
Consent may be withdrawn at any time.