Bloom Pediatrics
Nature. Nurture. Bloom.

friendship garden registration fall 2019

Support social thinking and inspire friendships through gardening! During each group meeting, your child will learn social thinking concepts and practice self-regulation techniques while planning and creating a garden filled with vegetables, flowers, and succulents.

friendship garden REGISTRATION
fall 2019

Enrollment is limited. If a group is full but not indicated as such, you will be notified and placed on a waiting list at no charge.
Parent Name *
Parent Name
Phone *
Address *
Parent #2 Name (Optional)
Parent #2 Name (Optional)
Parent #2 Phone (Optional)
Parent #2 Phone (Optional)
Child Name *
Child Name
Date of Birth *
Date of Birth
Please answer the following questions to help us better understand your child and ensure a positive and fun experience at Bloom.
You will be asked these questions again at the conclusion of the group. This information will help us measure your child’s progress and overall group effectiveness. Please how much you agree or disagree with the following statements.
1. My child is able to behave appropriately in a group (i.e. follows directions, keeps a calm body, stays seated, etc.). *
2. My child is able to initiate conversation with peers. *
3. My child is able to engage in play with a group of peers. *
4. My child is able to tolerate frustration. *
The following are taken directly from the Sensory Processing Measure by L. Diane Parham, Ph.D., OTR/L, FAOTA, and Cheryl Ecker, M.A., OTR/L Please answer the questions based on your child’s typical behavior during the past month.
1. Does your child play with friends cooperatively (without lots of arguments)? *
2. Does your child interact appropriately with parents and other significant adults (communicates well, follows directions, shows respect, etc.)? *
3. Does your child share things when asked? *
4. Does your child carry on a conversation without standing or sitting too close to others? *
5. Does your child maintain appropriate eye contact during conversation? *
6. Does your child join in play with others without disrupting the ongoing activity? *
7. Does your child take part in appropriate mealtime conversation and interaction? *
8. Does your child participate appropriately in family outings, such as dining out, or going to a park, museum, or movie? *
9. Does your child participate appropriately in family gatherings, such as holidays, weddings, and birthdays? *
10. Does your child participate appropriately in activities with friends, such as parties, going to the mall, and riding bikes/skateboards/scooters? *
Attendance and Financial Agreements *
All boxes must be checked in order to complete registration.
Consent for Use of Equipment *
All boxes must be checked in order to complete registration.
Sick Policy *
All boxes must be checked in order to complete registration.
Communication and Correspondence *
We will share your child’s progress as well as discuss other information about your child after their time at Bloom. We want to ensure your child’s privacy and be considerate of any confidential information that may be part of this discussion. Please check which methods of communication you feel are appropriate for conversation. If you select only the text message, phone and/or email options, we may end your child’s session a few minutes early to allow for adequate time to communicate with you.
Video and Picture Consent *
If you choose to decline permission now or to revoke your permission at any time in the future, you may do so without any impact on your child's care at Bloom.
Social Media and Web Consent *
If you choose to decline permission now or to revoke your permission at any time in the future, you may do so without any impact on your child's care at Bloom.
HIPAA Notice of Privacy Policies *
HIPAA NOTICE OF PRIVACY PRACTICES In compliance with the Health Insurance Portability and Accountability Act’s Privacy Rule (HIPAA), your child’s private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your child’s care and with payers, HIPAA requires that your child’s PHI be kept private and that you are notified of the privacy practices with respect to your child’s PHI. A summary of the policies follows. MEDICAL INFORMATION Your child’s PHI may consist of evaluations, diagnosis, daily notes, progress notes, Individual
Family Service Plan (IFSP) Individualized Educational Plan (IEP), insurance information, physician prescriptions, and correspondences to your other medical and educational providers (e.g., physician, therapists, service coordinators, psychologists, social worker, school personnel, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your child’s records will be kept in a file with his/her name on it. These files are stored in a locked container in your therapist’s home office or in a central file at our office. Your child’s records may also be stored in a computer only accessible to your child’s therapist(s). 
 • Correspondence with others regarding your child’s PHI will only include other members or your current child’s healthcare provider team to discuss your child’s course of treatment. 
 • At your request, correspondence with outside consultants or educational personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your child’s healthcare team or payer will be conducted on a private phone line in a confidential manner, so others cannot hear the conversation. 
 • All faxed information about your child will include a fax coversheet with a confidentiality statement. No confidential information about your child will be included on the fax cover sheet. 
 • Correspondence by mail will be addressed to specific individuals for the purpose outlined above. 
 • A written record of all disclosures of your child’s PHI will be kept. 
 • Only the Minimum Necessary Requirements will be disclosed to the entity requesting information. This means that only the minimum amount of information necessary to complete the task for which the entity is requesting the information will be provided, rather than sending the entire le. 
 • Your child’s therapist is your child’s Privacy Officer. Each therapist is responsible for protecting your child’s PHI and following these guidelines. 
 • Your child’s records will be kept and stored for a minimum of 6 years. After this time, the records will be shredded to protect privacy. YOUR RIGHTS UNDER HIPAA • You have the right to inspect and copy your child’s personal health information. The request must be made in writing. 
 • Your child’s PHI will be used strictly for evaluation and treatment planning. 
 • You have the right to request information about who PHI has been released to. 
 • You have the right to take away permission to disclose information to any party at any time. This request must be made in writing. • You have the right to complain if you believe your privacy rights have been violated. if you feel your rights have been violated, please contact us. You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights at, 877.696.6775, or U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, SW; Washington, D.C., 20201. We will not retaliate against you for filing. SUMMARY OF RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will give you a hard copy of this notice and follow the duties and privacy practices described in this notice. We will not use or share your information other than as described here unless you tell us in writing that we can. You may also change your mind at any time and let us know in writing if you do. Additional information is available at TERMS OF CHANGE We can change the terms of this notice. Any changes to this notice will be available to you upon request, on our website, or office. These changes will apply to your information we have on file.
Please list someone other than a parent.
Phone *
Since all communications made within the confines of a therapeutic relationship are confidential, it is necessary for this office to request a signed authorization in order to exchange any information related to this type of confidential relationship. This release of information may be revoked at any time through a signed statement and will expire one year from the date of authorization.
Today's Date
Today's Date
Payment Method *
Please select preferred form of payment below. To keep the cost of services down, Venmo @bloompediatrics, PayPal at, or check are preferred forms of payment. Invoices are sent via email and payment in full is due when invoice is received unless prior alternate arrangements have been made. Credit card information is required for registration fee and security of payment.
Name on Card *
Name on Card
Payment Authorization
$100 non-refundable registration fee to be charged to the card and applied towards balance due.