Consent for Private Therapy
(*)

Invalid Input
, to attend private speech and language therapy services in the office of Rock Therapeutic Services LLC. I give permission for my child’s/my own therapy program to follow any current communication goals, as well as those determined necessary by the clinician. I have read the furnished Policy and Procedures information and accept the terms stated within.
Signature
Invalid Input
(*)
Invalid Input
Patient’s Name (if 18 or older) or Guardian’s Name (if patient is 17 or younger)
Invalid Input
(*)
Invalid Input
Captcha (*) Captcha
  Refresh
Invalid Input