​I/We, the parent(s) of ________________________, agree to have him/her receive individual educational support.  We understand and agree to the following conditions:

 

Philosophy

• My goal is to support families and individuals with learning challenges. I seek to listen, understand, select the most effective and appropriate instructional methods/materials to encourage learning readiness.

• Educational support usually involves several months of work. The amount of time depends on various factors including severity of deficits and level of commitment to the program.

• Educational support does not seek to improve academic areas directly as tutoring does, but instead focuses on improvement of a person’s areas of difficulty in perceptual, sensory and cognitive processing, seeking to teach how to learn, not what to learn.

• Educational support seeks to improve processing in a gentle, holistic and hands-on way.

• Parental involvement and student cooperation are keys to the success of the program. Diligence and regularity in completion of homework/exercises are essential for progress.

Services

• Period of agreement:_______________ to______________

• The number and frequency of sessions will depend on the nature of the specific intervention. You will be advised in advance.

• There will not be therapy sessions during regularly scheduled school vacations unless agreed upon by both parties.

• Summer sessions will be scheduled flexibly.

Fees

• Initial contact: No charge

• Consultation: Approximately 1 hr: $100 + (payable the day of the consultation)

• Initial Assessment: $500+ Parents will be informed before the assessment what the cost of the assessment will be. Payable after the report has been emailed to parents.

• Program Development: $150 (this will be updated regularly)

• Subsequent Sessions: $75/hour (this will include all supplies (pen lights, saccade frames, reading pages, etc.))

• Payments can be made through e-transfer to earlybirdlearningconsultant@gmail.com. Payments are expected on a monthly basis. If payments are late one reminder will be issued.

• Unpaid invoices will be charged an additional 5% after 2 weeks and 25% after 4 weeks late.

Parental Involvement

• Attend assessment and parent training

• Carry out vision exercises, rhythmic movements and/or supervise Rhythmic Writing at home on non-therapy days and supervision of other assigned homework

• Purchase of a chalkboard (3’x5’ minimum) if participating in the Rhythmic Writing (part of Search and Teach).

• Replacement of all borrowed materials if damaged or lost.

Absences

• Sessions cancelled due to therapist illness or schedule conflict will be made up.

• No-shows without prior notice or arrangements will be billed for the missed session. For extenuating circumstances, alternative arrangements may be considered.

Observation

The parents/student give permission to be observed during therapy sessions on occasion by persons invited by the therapist.  The parents/student give permission to have sessions recorded live for the purpose of therapist evaluation requirements and client progress monitoring. 

Yes/ No          Signature: _______________________________

Media sharing:  I give my permission for my child’s picture to be taken and shared on Early Bird Learning’s Facebook Page/Website.  No identifying information will be shared. 

Yes / No          Signature: _______________________________

Disclaimer

While most clients see improvements, Early Bird Learning cannot guarantee improved perceptual, cognitive, and academic performance.Some students experience a regression before they experience progression

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By signing this form, we acknowledge that we understand the information given and agree to the terms as stated in this agreement.

 

         

Parent                                                                                          Date                                  

         

Therapist                                                                                     Date