Student PT Guidelines

Student PT Guidelines

Purpose: These guidelines set forth the scope, responsibilities, and consent parameters for school-based Physical Therapy (PT) services provided to the student named below. Physical Therapy services are delivered as part of the student's educational program and, where applicable, in coordination with Individualized Education Programs (IEP) or 504 plans. The parent/guardian or adult student must acknowledge understanding of the practices, privacy protections, scheduling procedures, and conditions under which PT may be provided or declined.

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian or Primary Contact

Primary Phone:    Email:

Medical / Health Information

Emergency Contact Name:    Phone:

PT Service Details

One-time evaluation    Weekly — 1x    Weekly — 2x    Consultative / As-needed

Session Duration:    Typical Location(s):

Proposed Start Date:    Anticipated Review Date:

Policies, Confidentiality, and Authorization

1. Authorization for Treatment: I hereby authorize the school-employed or contracted physical therapist to evaluate and provide routine PT services to the student named above during regular school hours and at school-sponsored activities when indicated. I understand that services are provided in accordance with the student's educational plan and documented goals.

2. Coordination and Release of Records: I consent to the release and exchange of health and education records related to provision of PT services among the school, treating therapists, case manager, and other designated educational or health professionals when necessary to plan and implement services. Such disclosures shall be limited to information relevant to the student's treatment and educational needs.

3. Privacy Protections: The school will maintain confidentiality of health records in accordance with applicable law. Information about the student's PT services will be included in educational records and handled pursuant to the school's privacy policies.

4. Emergency Care: If the student requires emergency care during PT services, school health staff will provide or arrange immediate care and notify the parent/guardian or emergency contact. Authorization for emergency medical treatment is requested below.

5. Risks and Benefits: I acknowledge that PT has potential benefits and may involve risks, including temporary discomfort. Therapists will take precautions to minimize risks. I accept responsibility to report changes in the student's health or medication that may affect PT services.

6. Attendance, Cancellation, and Noncompliance: The school will make reasonable efforts to schedule sessions. Repeated cancellations, nonattendance, or refusal of services by the student may result in modification or discontinuation of services after team review.

7. Revocation: Consent may be revoked in writing at any time. Revocation shall not affect actions already taken in reliance upon this consent.

Consent & Acknowledgment

Please indicate your choices by checking the boxes below and signing at the end of this form.

I authorize provision of school-based Physical Therapy as outlined above.    I authorize emergency care if needed during PT sessions.

I authorize release of PT-related records to medical and educational providers as necessary for coordination of care.

Certification: By signing below I certify that I am the parent/legal guardian of the student or the student is an adult and that the information provided is accurate to the best of my knowledge. I understand the policies and consent terms above and authorize the provision of PT services in accordance with those terms unless and until I revoke consent in writing.

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