Consent for Private Therapy

, 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.

Patient’s Name
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by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.