Free Physical Therapy, Occupational Therapy, Speech Therapy and Special Education Tutorials for Children For Parents or Guardians of Child or Client ◉ Name of Client or Child Name of Child (Pangalan ng Kliyente) * First Name Last Name ◉ MEDICAL INFORMATION (MEDIKAL NA IMPORMASYON) Primary Diagnosis (Pangunahing Diagnosis) * CHOOSE 1 (CHOOSE ONE) ONLY / ISA LAMANG ANG PILIIN ADHD Amputation Amyotrophic lateral sclerosis Autism Cerebral Palsy Cerebro-vascular accident/Stroke Down Syndrome Feeding Disorder Fractures Global Developmental Delay Hearing Impairment Intellectual Disability Language Delay Learning Disability Mood Disorder Myocardial infraction/heart attack Parkinson's disease Personality disorder Pulmonary disorder Schizophrenia Spinal Cord Injury Traumatic Brain Injury Visual Impairment Others, please specify: Service Requested * Check all that apply Occupational Therapy Physical Therapy Speech Therapy Do you have a referral from a doctor for the requested therapy? (Mayroon ka bang referral mula sa isang doktor para sa hinihiling na therapy?) * Yes No Name of Primary and/or Referring Doctor (Pangalan ng pangunahing/nag-refer na doktor) Child’s Date of Birth (Araw ng Kapanganakan) MM DD YYYY Child’s Address (Tirahan) * Country (Bansa) * Philippines Region (Rehiyon) NCR – National Capital Region Region I – Ilocos Region Region II – Cagayan Valley Region III – Central Luzon Region IV‑A – CALABARZON MIMAROPA Region Region V – Bicol Region Region VI – Western Visayas Region VII – Central Visayas Region VIII – Eastern Visayas Region IX – Zamboanga Peninsula Region X – Northern Mindanao Region XI – Davao Region Region XII – SOCCSKSARGEN Region XIII – Caraga CAR – Cordillera Administrative Region BARMM – Bangsamoro Autonomous Region in Muslim Mindanao Province (Lalawigan) Abra Agusan del Norte Agusan del Sur Aklan Albay Antique Apayao Aurora BARMM: Bangsamoro Autonomous Region in Muslim Mindanao Basilan Bataan Batanes Batangas Benguet Biliran Bohol Bukidnon Bulacan Cagayan Camarines Norte Camarines Sur Camiguin Capiz CAR: Cordillera Administrative Region Catanduanes Cavite Cebu Cordillera Administrative Region Cotabato Davao de Oro Davao del Norte Davao del Sur Davao Occidental Davao Oriental Dinagat Islands Eastern Samar Guimaras Ilocos Norte Ilocos Sur Iloilo Isabela Kalinga La Union Laguna Lanao del Norte Lanao del Sur Leyte Maguindanao Marinduque Masbate Misamis Occidental Misamis Oriental Mountain Province NCR: National Capital Region Negros Oriental Northern Samar Nueva Ecija Nueva Vizcaya Occidental Mindoro Oriental Mindoro Palawan Pampanga Pangasinan Quezon Quirino Rizal Romblon Samar Sarangani Siquijor Sorsogon South Cotabato Southern Leyte Sultan Kudarat Sulu Surigao del Norte Surigao del Sur Tarlac Tawi-Tawi Zamboanga del Norte Zamboanga del Sur Zamboanga Sibugay ◉ PARENT/GUARDIANS INFORMATION (IMPORMASYON SA MAGULANG/GUARDIAN) Parent/Guardian Name (Pangalan ng Magulang/Guardian) * First Name Last Name Facebook Account/Username Relationship with Child (Kaugnayan sa Kliyente) * Parent (Magulang) Guardian (Tagapangalaga) Others Email Address * Mobile Number * (Please follow format 09XXXXXXXXX) Do you have any financial constraints/challenges that make access to therapy and education services difficult? (Kayo ba ay nakakaranas ng problema/hamong pinansyal na nagpapahirap sa pagkuha ng serbisyong therapy at edukasyon?) * Yes No Describe your financial constraints/challenges in accessing therapy services (Ilarawan ang problema/hamong pampinansyal sa pagkuha ng serbisyong therapy) * Extreme financial constraints (Matindi) High financial constraints (Mataas) Moderate financial constraints (Katamtaman) Minimal financial constraints (Mababa) No financial constraints (Wala) Highest Educational Level Completed (Pinakamataas na antas ng pinag-aralan) * Can only choose 1 Pre-school Elementary Highschool College Graduate School Others, please specify: How did you know about us? Choose all that applyy (Paano mo nalaman ang tungkol sa amin?) * Doctor Therapist Website Facebook Fellow parents TV / newspapers Brochures Conference Teacher Others, please specify: Pertinent precautionary measures to consider (Mga mahalagang hakbang sa pag-iingat na dapat isaalang-alang): Check the area/s where the client has concerns with (I-check sa mga pagpipilian ang mga concern ng kliyente) * (Check all that apply) Behavior regulation Cognition Communication Movement Play and recreation skills School and education skills Self-help skills Sensory Social skills Work skills ◉ CHIEF COMPLAINTS AND GOALS (MGA PANGUNAHING HINAING AT LAYUNIN) What is/are the client's main concerns? (Anu-ano ang mga pangunahing hinaing ng kliyente?) What are the most important skills/behaviors that the client must learn/develop? (Anu-ano ang mga pinakamahalagang kasanayan/pag-uugali na nais ituro sa kliyente?) Client/Child Schedule (Iskedyul ng kliyente) For convenience, we encourage you to set a recurring client/child schedule. For example, “Every Wednesday from 8:00 AM to 10:00 AM” or “Every 1st Friday of the month from 4:00 PM to 6:00 PM.” While your preference will be considered, please note that the final schedule will be confirmed with you by our team. Should you have changes, please inform the admin for changes in schedule. (Para sa kaginhinhawa, hinihikayat ka naming magtakda ng umuulit na iskedyul ng kliyente/bata. Halimbawa, "Tuwing Miyerkules mula 8:00 AM hanggang 10:00 AM" o "Tuwing unang Biyernes ng buwan mula 4:00 PM hanggang 6:00 PM." Habang isasaalang-alang namin ang iyong kagustuhan, pakitandaan na ang panghuling iskedyul ay kukumpirmahin sa iyo ng aming koponan. Kung mayroon kang mga pagbabago, mangyaring ipaalam sa admin para sa mga pagbabago sa iskedyul.) Additional Notes: Please write any other pertinent personal information that may affect services to be provided. (Itala and iba pang personal an impormasyon na makaaapekto sa serbisyong ibibigay) Notice Once you submit, your request will be reviewed by the admin. You will receive feedback regarding your application through the email you provided. (Ang iyong aplikasyon ay susuriin ng admin. Kayo ay makatatanggap ng tugon sa email na iyong ibinigay.) Client Service Agreement PURPOSE OF THE CONSENT FORM The purpose of this form is to provide you with information about the conduct of remote Physical Therapy, Occupational Therapy, Speech and Language Therapy, education tutorials and/or related services from the REACH Foundation, Inc. as duly referred by a physician, and to obtain your consent to participate. PARTICIPATION Participation in this program is voluntary. You have the right to withdraw at any time without any penalty. By allowing your child to participate in this activity, you authorize the partner organization to register your child’s information in the REACH Foundation, Inc. database. This is important to keep track of your child’s progress in therapy, and for service delivery data analysis. You are responsible for coordinating with the representative of the partner organization regarding the following aspects of the teletherapy session, including but not limited to: scheduling, conduct of the actual session, and access to home programs. You are also tasked to accompany your child to the designated venue as instructed by the partner organization. Lastly, you are assigned to perform the home programs upon the direction of your assigned therapist. SCOPE OF SERVICES FOR THE FAMILY/CLIENT The REACH Foundation, Inc. agrees to provide the needed services to the Family/Client whenever possible by its volunteers, staff, interns and partners. PERIOD COVERED The terms of this agreement will begin upon the REACH Foundation Inc.’s confirmation of the Family/Client’s request for therapy, educational and/or related services and shall end once the Family/Client has stopped receiving these services. The REACH Foundation, Inc. reserves the right to modify the duration of this agreement if, in its professional opinion, the Family/Client’s and the context’s condition calls for it. FREE SERVICE Families will receive necessary teletherapy services free of charge CANCELLATION POLICY The Family/Client agrees to provide the partner organization with at least twenty four (24) hours notice of any cancellation of a scheduled session. If the Family/Client fails to provide such notice without valid reason, the Family/Client may be deprioritized by the partner organization in the scheduling of the next therapy sessions. CONFIDENTIALITY The REACH Foundation, Inc. shall maintain the confidentiality of all information related to the Family/Client’s therapy, including but not limited to, the Family/Client’s personal information, medical history, treatment plan, and progress. The volunteer service providers shall likewise not disclose any such information to any third party without the Family/Client’s written consent, except as required by law. Contact information of Family/Client is to be shared with potential volunteer therapists for coordination of therapy sessions. Notice: You will receive a confirmation through the email you provided. (Kayo ay makatatanggap ng kumpirmasyon sa email na iyong ibinigay). Certification • I hereby certify that the foregoing information is true and correct. I understand that any false statement or information in this application may render my application void. (Sa pamamagitan nito, patutunayan ko na ang mga naunang impormasyon ay totoo at tama. Naiintindihan ko na ang anumang maling pahayag o impormasyon sa application na ito ay maaaring magpawalang-bisa sa aking aplikasyon.) • I certify that the information given herein is correct and complete. Deletion and/or falsification of information on this form may nullify my application and/or dismiss me from the volunteer program. (Patutunayan ko na ang impormasyong ibinigay dito ay tama at kumpleto. Ang pagtanggal at/o palsipikasyon ng impormasyon sa form na ito ay maaaring magpawalang-bisa sa aking aplikasyon at/o i-dismiss ako mula sa volunteer program.) • I have read and understood the terms and conditions. (Nabasa ko at naintindihan ko ang mga tuntunin at kondisyon.) You have successfully filed your application for free services. Please wait for our team to get back to you.
