Consent for Services Form

Parent or guardian's first name and last name
Child's first name and last name
Child's first and last name

1. These services are to include one or more of the following and will be invoiced according to the Pathways hourly rate(s):

a) Screening

b) Assessment

c) Intervention

d) Written reports

e) Participation in team meetings as required

f) Consultation with parents and team members

g) Referrals to other professionals as deemed appropriate by the Parents/Guardians and the therapist

h) Selection and implementation of augmentative and alternative communication devices

i) Preparation of home programs

j) As a parent/guardian, you may be asked to complete activities or carry out recommendations at home.  This assistance will support your child’s program.  You are welcome to attend scheduled sessions.

2. The rate charged by Pathways Pediatric Services to the Parents/Guardians for the above services will range from $123.65 - $161.25 per hour based on the type of service.  All therapy sessions may be subject to indirect fees which may vary from 10 minutes to 15 minutes of billable time.  Indirect fees include consultation, preparation, documentation, coordination, etc.

3. Pathways Pediatric Services will charge for preparation of written reports as per our hourly fee schedule.  Reports will be written following as assessment and/or upon request.

4. Pathways Pediatric Services requires a minimum of 24 hours’ notice for cancelled sessions.  If notice is not received, Pathways retains the right to invoice for missed appointments, exceptions apply of course.

By checking this box, I give permission for my child to receive services at school/daycare. I understand that my child may be seen for therapy sessions by a Pathways therapist and/or representative of Pathways in a separate room/classroom. I give permission for my child to receive services within and outside the classroom.  I understand that I may attend sessions by notifying the therapist in advance.

By checking this box, I give permission for my child to receive services via teletherapy.  I understand that teletherapy includes the use of interactive audio, video or data communication. I understand that I have the right to withhold or withdraw consent at any time.


I understand that the therapist who provides services via teletherapy will protect the privacy and confidentiality of my child, using the safeguards established by the technology. I understand that no technological communication system is entirely secure.


I understand I am responsible for:

  • Providing the necessary connective device for my child’s sessions,
  • Maintaining information securely on my device,
  • Attending scheduled appointments.

I understand the risks associated with teletherapy include but are not limited to the following: children may become more aware of strengths and weaknesses, technical difficulties may arise, transmission of information may be disrupted or distorted, information could be interrupted or accessed by unauthorized persons.


I understand the benefits associated with teletherapy include but are not limited to the following: a child has access to therapy at this time, allows for the child to continue with regular therapy, and helps your child achieve goals and outcomes.


By checking this box, I give consent to Pathways Pediatric Services to collect information pertinent to my child’s development.

By checking this box, I give my consent to Pathways Pediatric Services to share/release information pertinent to my child’s development with Pathways and their working partners.