Permission to Evaluate and Provide Treatment
Please complete the form below to grant permission and authorize a screening, comprehensive speech and language evaluation, and/or treatment (as needed) for your child. Speech-language evaluations consist of standardized testing, informal and formal observations, and clinical judgment.
Client's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Permission Statement
I authorize and grant permission to AGB Speech Therapy, to evaluate and/or provide necessary speech/language treatment/therapy services to my child who is named above. Treatment is based upon the findings of the evaluation and the recommendations of the responsible speech-language pathologist.
Parent/Guardian Name
*
First Name
Last Name
Signature
*
Date
*
/
Month
/
Day
Year
Date
Should be Empty: