hereby request and consent to Family Guidance and Therapy Center to perform treatment and care for my child as prescribed by a physician and/or recommended by an occupational therapist. I understand and am informed that, as in the practice of medicine, occupational therapy may have some risks. I understand that I have the right to ask about these risks and have any questions answered about my child’s condition, prior to treatment. I have carefully read and fully understand this Informed Consent Form and have had the opportunity to discuss it with the treating therapist. I consent and authorize Family Guidance and Therapy Center to administer treatment under the direction and supervision of a registered occupational therapist.