School Therapy Consent Form
Please complete this form to provide consent for your child to participate in school-based therapy sessions.
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade/Class
*
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Therapy Requested
*
Please Select
Speech Therapy
Occupational Therapy
Physical Therapy
Counseling
Other
Reason for Therapy / Areas of Concern
*
Parent/Guardian Signature
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: