Forms

TERMS OF SERVICE AND PAYMENT FORM (”Terms”)

Your access to and use of services provided by the ”Company” is conditional on your acceptance and compliance with these Terms. By accessing our service you agree to be bound by these Terms, including financial responsibility for any services rendered. We may terminate or suspend access to our services immediately, without prior notice or liability, for any reason whatsoever, including without limitation if you breach the Terms. Services provided by the “Company” are informational in nature only and there is no guarantee of specific outcomes for the child.

Services are provided across the USA through online video calls set by appointment and optional personal visits, set by appointment, to your home IF you live in West Omaha. Online video calls are made through the apps, FaceTime, Google Duo, or Skype.

Services are initiated by contacting the ”Company” by email for preliminary information (promero0053@gmail.com) and to set an appointment time, appointment length, and mode of contact. Cost of services is listed below. Prepayment for a minimum of 30 minutes is required to initiate an appointment. Payment of services which extend beyond the prepayment for a session are due within 24 hours of the appointment.

Payments may be made via PayPal at promero0053@gmail.com.

Service Fees:

A 30 minute appointment is the minimum service time requiring a payment of $30.00 in advance of the appointment. If the appointment lasts longer than the prepaid time of 30 minutes, the fee is an additional $15 for each additional 15 minutes or part of a 15 minute period.

30 minutes = $30, plus 2 brief follow-ups by email or video (Marco Polo) within the month

45 minutes = $45, plus 3 brief follow-ups by email or video (Marco Polo) within the month

60 minutes = $60, plus 4 brief follow-ups by email or video (Marco Polo) within the month

A prepaid purchase of a package of 3 sixty-minute sessions (prepayment of $180) earns 60 FREE minutes. The resulting total of 240 minutes from the prepaid purchase can be used for payment of any of the session lengths over several months.

Brief follow ups by email involve asking a few questions for clarification, or commenting on progress, with 1 follow up email from the “Company“ addressing the parent’s information. This constitutes 1 follow up. The email must be initiated by the parent. The follow ups must occur within 1 month of the appointment. All follow ups, even unused, expire at 1 month from the appointment.

The app Marco Polo may be used instead of an email for a follow up. The parent can take a short video clip of the child (one clip less than 1 minute or up to 3 clips of 20 seconds or less each) in which the parent narrates any questions, concerns, or comments. All clips must be sent at the same time to count as 1 brief follow-up. A private link via YouTube video may also be used. The “Company” will address the parent’s information in a follow up by a video clip in Marco Polo or via email. The video clip must be initiated by the parent. The follow ups must occur within 1 month of the appointment. All follow ups, even unused, expire at 1 month from the appointment.

In the event of technical difficulties, such as power or internet outages, every effort will be made to reschedule the appointment or give credit towards a future appointment.

By signing below you are agreeing to the Terms of Service including financial responsibility for any services rendered.

Parent Signature:

Date:

RELEASE OF INFORMATION:

Information about your child, parent, and family will be kept confidential by the “Company” and not shared with anyone by means of verbal, print, audio / video, or in any digital format, unless you complete a Release of Information form to specifically identify the persons and format to whom you would like to share the information. You choose which and how much information you would like to share with the "Company" however, at a minimum a phone number or email is required to allow the "Company" to connect with you via a video call.

Information provided to you, your child, and your family by the “Company” in sessions or in email or video follow ups will not be shared with anyone else by means of print, audio / video, or in any digital format (including not posting on Facebook, Instagram, You Tube, etc).

By signing below, you give permission to share audio / video of yourself and your child with the “Company” for the purpose of gaining information about yourself to assist the "Company" in providing better consultation with you. You are acknowledging that this information will be kept confidential. You also are acknowledging that you will not share information provided to you by the “Company” in written or digital format to others. This agreement is ongoing and valid for one year from the date below. This agreement can also be reviewed and modified at any time by making a request through email to promero0053@gmail.com.

Parent Signature:

Date:

Provider Signature:

Date:

INITIAL INFORMATION FORM

Child’s Name: Child’s Birthdate:

Any relevant birth or medical history: (such as prematurity, illness, etc):

Any specific concerns? Or just seeking general information?

Parent’s Names:

Parent’s Address:

Parent’s Phone and Email Address:

Preferred Mode of Contact ( Facetime, Google Duo, Skype)

How did you hear about Penni’s Early Development Strategies?

PREPARING FOR YOUR SESSION:

You will need to place your phone, tablet, or electronic device somewhere in the room which allows a good view of the child but not close enough to be a distraction to the child. Try this out before your first session to have an idea of how this might work in your setting.

Penni will likely ask for an infant not yet walking to be placed on the floor, in sitting or on their tummy or on their back during the session. Prepare the area by having appropriate toys of interest closely available.

For older infants who are able to move around, plan to place the electronic device in a spot in which most of the room is visible. Prepare the area by having appropriate toys of interest closely available.

For preschool children, Penni will send you specific instructions on electronic device placement based on what areas of development that parents wish to address.