Treatment Agreement • TinyEYE

Referred by...

Did a person or organization send you to this page to fill in the Treatment Agreement ?*

Yes
No

Name of person or organization referring you*

2

Are you the one who needs therapy ?

Are you the one who needs therapy ?*

Yes
No

3

Contact details parent / guardian/ carer

Name contact person*

E-mailadres contact persoon*

Telephone number contact person

4

Details Client (person receiving therapy)

Name client*

Client E-mail address

Client e-mail address*

Client telephone number

Client telephone number*

BSN client (NL only)

Client native language

Client address street name*

House number*

Postal code*

City/ town/ village residence*

Current country of residence*

Client's gender*

Male
Female
Prefer not to share

Client date of birth*

Client age

(enter numbers only)

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5

Medical insurance details

Client's medical insurance company

Client's medical insurance number

(enter numbers only)

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Description of the speech therapy support needed

Is there a medical referral (by your doctor)?*

Yes
No

Name of referrer*

Date referral*

Client's general practitioner

Upload your referral letter here

Max. file size: 768 MB.

In what language should the therapy take place?

Speech Therapy Issue*

SPEECH THERAPY ISSUE. An online test of the client will be carried out. On the basis of the test results, the speech therapist sets the speech therapy goals. The start date of the treatments, the frequency of speech therapy treatment per week, and the number of scheduled sessions before the evaluation interview are determined in consultation with the treating speech therapist.

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General conditions TinyEYE online speech therapy

Requirements*

Select to indicatie that you have taken note of our conditions relating to REQUIREMENTS

Select All
An adequate internet connection
A properly functioning modern computer
Additional requirements: see link to PRACTICE RULES AND TIPS FOR TinyEYE ONLINE SPEECH THERAPY

Treatment*

Select to indicatie that you have taken note of our conditions relating to TREATMENT

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To make or cancel appointments the Speech Therapy Practice is reachable from Monday to Friday (08.00 t/m 18.00 ) through e-mail, Skype or telephone through the contact details published on the website www.tinyeye.eu
Appointments must be cancelled in time, at least 24 hours before the scheduled appointment See contact details on our website, www.tinyeye.eu.
Appointments that are late will be cancelled, and no-shows will be personally charged in full to you (not to your insurance company). If a treatment session cannot proceed or is aborted, and you are responsible because of inadequate internet on your location and / or insufficient computer performance of your computer, the session will be personally charged to you (and not your health insurance), unless there is evidence of force majeure.
If you receive a therapy session from another therapist on the same day as your session with our therapist, this means we cannot charge your insurance company; the session will then be personally charged to you (and not your health insurance).
You are strongly advised to practice at home between sessions, to increase the effectiveness of the therapy and reduce the number of therapy sessions required to achieve your therapy goals. Follow the advice your Speech Therapist gives you from time to time.
Evaluation of the therapy will take place after the agreed number of sessions

Security*

Select to indicatie that you have taken note of our conditions relating to SECURITY

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You and your carer are required to keep your access codes to TinyEYE secret.
Patient records are required by law to be stored for 15 years. After 15 years the records will be destroyed by the owner of the Practice.

Tariffs (only for Dutch insured clients)*

Select to indicatie that you have taken note of our conditions relating to TARIFFS

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Therapy sessions are reimbursed in full by almost all Dutch medical insurances.
For treatment of persons older than 18 years the clients's own risk applies, thereafter treatment is covered by the Dutch medical insurance.
In cases that a client is not insured by a medical insurance company we apply the tariffs of our practice, as laid out in our quotation to you.
You can find an overview of the Dutch medical insurance companies that reimburse online speech therapy on www.tinyeye.eu.

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Permissions

EXCHANGING INFORMATION Permision for cooperation with third parties and requests for information*

The Speech Therapist shall work together with the family doctor, teachers and other medical specialists. Do you consent to the co-operation and exchange of medical details with other medical specialists ?

Yes
No

MONITORING Permission for incidental remote monitoring*

For training and coaching purposes therapy sessions may incidentally be monitored remotely. Please indicate your consent

Yes
No

VIDEO RECORDING Permission for making video recordings*

The effectiveness of online therapy is enhanced when the speech therapist, where necessary, can make video recordings of a therapy session. Please indicate your consent for making video recordings:

Yes
No

Date agreed*

Signature client*

Agreed and declared to have read the conditions:

Signature parent/guardian/carer*

Signature parent/carer For the client: Agreed and declared to have read the conditions:

Agreement with privacy policy*

PRIVACY POLICY
We are aware that you have confidence in us. We therefore see it as our responsibility to protect your privacy. On this page we will let you know what information we collect when you use our website, why we collect this data and how we improve your user experience. This way you understand exactly how we work.
This privacy policy applies to the services of TinyEYE Europe. You should be aware that TinyEYE Europe is not responsible for the privacy policies of other sites and sources. By using this website you accept the privacy policy.
TinyEYE Europe respects the privacy of all users of its site and ensures that the personal information you provide is treated confidentially.
OUR USE OF COLLECTED DATA
USE OF OUR SERVICES
When you sign up for one of our services, we ask you to provide personal or company details. This data is used to perform the service. The data is stored on secure servers of TinyEYE Europe or those of a third party. We will not combine this information with other personal information we have.
COMMUNICATION
When you send e-mail or other messages to us, we may retain those messages. Sometimes we ask you for your personal details that are relevant to the situation in question. This makes it possible to process your questions and answer your requests. The data is stored on secure servers of TinyEYE Europe or those of a third party. We will not combine this information with other personal information we have.
COOKIES
We collect data for research in order to gain a better insight into our customers, so that we can tailor our services accordingly.
This website uses “cookies” (text files placed on your computer) to help the website analyze how users use the site. The information generated by the cookie about your use of the website can be transferred to secure servers of TinyEYE Europe or those of a third party. We use this information to keep track of how you use the website, to compile reports on website activity and to offer other services relating to website activity and internet usage.
TURN OFF COOKIES
Most browsers are set to accept cookies by default, but you can reset your browser to refuse all cookies or to indicate when a cookie is being sent. However, some features and services on our and other websites may not function properly if cookies are disabled in your browser.
PURPOSES
We do not collect or use information for purposes other than the purposes described in this Privacy Policy unless we have obtained your consent in advance.
THIRD PARTIES
The information will not be shared with third parties. In some cases the information can be shared internally. Our employees are obliged to respect the confidentiality of your data.
CHANGES
This privacy statement is tailored to the use of and the possibilities on this site. Any changes and / or changes to this site may lead to changes to this privacy statement. It is therefore advisable to consult this privacy statement on a regular basis.

I agree with the privacy policy.*

These are the details we need from you

Referred by...

Are you the one who needs therapy ?

Contact details parent / guardian/ carer

Details Client (person receiving therapy)

Medical insurance details

Description of the speech therapy support needed

General conditions TinyEYE online speech therapy

Permissions

Hello! My name is Mila.

Fill in your Treatment Agreement.

These are the details we need from you

Referred by...

Are you the one who needs therapy ?

Contact details parent / guardian/ carer

Details Client (person receiving therapy)

Medical insurance details

Description of the speech therapy support needed

General conditions TinyEYE online speech therapy

Permissions

Hello! My name is Mila.