Consent for Services
I authorize Optimize Speech-Language Therapy Services to render appropriate evaluation and therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Optimize Speech-Language Therapy Services in writing. In addition, Optimize Speech-Language Therapy Services may terminate services by notifying me in writing.
I do not give my consent or am withdrawing my consent regarding Optimize Speech Language Therapy Services rendering evaluation and therapy services to the client named below.
Print Name of Client
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2 digit month, 2 digit day, 4 digit year
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Client Date of Birth
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Year
2 digit month, 2 digit day, 4 digit year
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Signature of Parent or Caregiver
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Relationship to Client
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