Informed Consent for Treatment



  • IF SHARED CUSTODY: Both parties must complete this consent form prior to treatment.


  • Consent for Therapeutic Treatment

    I hereby attest that I have voluntarily applied for and entered into treatment, or give my consent for the minor or person under my legal guardianship, at EBS Children’s Institute of Oxford. I understand that I may terminate these services at any time.

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  • Involvement in Care and Services

    EBS encourages all clients and families to be an active member of the therapy session. Parent training and home generalization programs are critical for success and progress. I agree to be an active member of my child’s treatment plan.

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  • Consent for Participation with Therapeutic Equipment

    Intervention programs at EBS Children’s Institute of Oxford usually involve the use of specialized equipment such as various swings, bolsters, inflated therapy balls, climbing structures, tactile media (such as soap foam, Play-Doh, and lotion), and a variety of other activities that involve fine, gross, and oral motor coordination. Therapy activities often involve encouraging the child to try new things in order to foster increased skills and abilities. While EBS Children’s Institute of Oxford staff make great efforts to ensure each child’s safety, the nature of the therapeutic intervention includes the risk of falling, bumping into other people/equipment. I am aware of the inherent risk of this type of activity, and I give permission for my child to participate in therapy as described.

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  • Review of Records/Release of Information

    I consent to communication between EBS Children’s Institute of Oxford and other therapists, teachers, and/or doctors that have previously worked and/or are currently working with my child. I understand that information may be shared with another member of my child’s treatment team outside of EBS Children’s Institute of Oxford, as well as shared with professionals within EBS Children’s Institute of Oxford as part of the treatment process. I understand that the information that is released between the treatment providers is confidential and is for the well-being of my child.

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  • Consent for Videotaping & Photographing for Therapeutic Purposes

    Therapists often videotape or photograph children who receive therapy services at EBS Children’s Institute of Oxford to help monitor and document a child’s areas of concern, as well as progress. Videotapes and photos are used and reviewed only by EBS staff. Parents are welcome to view their child’s videotape at EBS.

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  • Consent for Videotaping & Photographing for Educational & Public Awareness Purposes

    Staff at EBS Children’s Institute of Oxford are frequently asked to teach at courses, seminars, or workshops. We often like to include videotape, slides, or photos during our presentations. Additionally, we may occasionally use photographs to share on social media and for promotional purposes.

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