Please read and complete the form below to acknowledge you consent to your child receiving treatment and that you have read and understand the HIPAA Privacy Practices.
I give permission to NeuroMotif to provide music therapy treatment as agreed upon in the best interest of my child.
I understand that I have the right to discuss any treatments, along with any potential risks and benefits, with my child’s music therapist.
I understand that I have the right to refuse any treatment.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights regarding the use and disclosure of my/my dependent’s protected health information. By signing this document, I acknowledge that I have received a copy of HIPAA Notice of Privacy Practices.