I have read and fully understand the privacy policy above:
Signature:
Clear
Printed Name
Date:
My Relationship to Child is:
Child's Full Name
Child's Date of Birth
I give permission to communicate with me by text or e-mail regarding my child’s therapy services although privacy as delineated by Hippa law cannot be guaranteed in these methods of communication:
Signature (2)
Clear
Signature Date:
Printed Name (2)
Relationship to Child
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