Learning Services Contract Agreement

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Learning Services Contract Agreement learning Services

Welcome to The Southfield Center for Development. Please take a few moments to thoroughly review this form as it contains important information regarding our office policies and procedures. Please feel free to jot down any questions so that they may be fully discussed. Once you sign this form, it will constitute a binding agreement between us.

The Southfield Center for Development looks forward to providing Academic Tutoring or Executive Functions Coaching services for your child.

Learning Services sessions are typically 60 minutes in length and occur weekly. You and your child’s Coach will determine together a schedule of sessions that will meet your child’s needs. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. In the case of sudden illness or other emergency, we are certainly willing to be more flexible.

Professional Fees:

Our fee is $130 per hour at the Center, and $150 per hour at your home. In addition to the session fee, we reserve the right to bill for any phone calls, email communication, or meetings with school staff or parents that exceed fifteen minutes in duration. This will be based on the hourly session fee. If attendance is required at a School Meeting, you will be billed at the applicable rate, not the session fee rate.

Illness Policy:

For the well-being and protection of all children being served at the Southfield Center, please reschedule your child’s session if he or she has had a fever or other contagious illness such as strep throat or stomach flu within 24 hours of scheduled session. If your child is taking penicillin or antibiotics please make sure they have been on them for at least 24 hours before coming in for therapy.

Cancellation Policy:

Cancellations for scheduled Learning Services sessions must be given 24 hours in advance, as this time has been reserved for your child. The hourly session fee or a prorated amount depending on length of individual child’s session will be charged for all missed appointments or cancellations made the day of scheduled session. In the case of sudden illness or other emergency, we can discuss rescheduling missed appointments.

Contacting Your Child’s Learning Services Coach:

Our Learning Services staff can be reached at the Center at 203-202-7654 during business hours. Due to our type of work, we are often not immediately available by telephone when we are with clients. When we are unavailable, our telephone is answered by a voice mail that is monitored frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available.

Payment Policy:

The Southfield Center for Development requires payment in full at the time of service. As such, it is recommended that you keep a credit card on file for ease of payment. To do so, please complete, sign and return the Credit Card Authorization form along with this agreement. If you prefer not to keep your card on file, payment is still required at the time of service. Please note that tutors do not collect fees, and all payments must be made directly through the center.

If your child is seen at home, or if you are not directly escorting your child to the Center for his or her appointments, we require that you keep a credit card on file. In these instances, your card must be on file in advance of your child’s first session.

Professional Records:

Parents please note, pursuant to federal guidelines, The Southfield Center keep protected health information about your child. This professional record includes your child’s clinical evaluations, a description of the ways in which your child’s learning services issues impacts their life, their diagnosis, a treatment plan, progress notes towards those goals, treatment history, any previous evaluations or Individualized Education Plan that have been received from other providers, reports of any professional consultations, and any reports that have been sent to anyone, including reports to your school.

Permission to Release/Exchange Information Between Southfield Center Practitioners:

The Southfield Center for Development is a multidisciplinary child development center that provides diagnostic, therapeutic and educational services in a collaborative environment. Our clinical and administrative team is dedicated to helping children and adolescents achieve their full potential. The exchange of information between Southfield Center providers, including but not limited to psychologists, psychiatrists, social workers, marriage and family therapists, speech pathologists, occupational therapists, learning specialists, education advocates, and executive functions coaches (collectively “Providers”), is part of what allows us to provide the highest level of service to the children and families we serve.

By signing this contract, you authorize information release/exchange concerning your child (or yourself, if you are the client being seen, and are 18 years of age or older), among Southfield Center providers. You understand that this information may be used for the provision of services, exchange of treatment information, diagnosis, progress and historical data, and continuation of the provision of services. You also understand that it is your right to revoke consent at anytime, except to the extent information has been released, obtained, or exchanged as originally permitted.

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