FORM NAME

DESCRIPTION

First and Last Name *

Please check all that apply: I provide consent to Therapy Spot to take PHOTOGRAPHS of me for the purposes of: *

Therapy Progress tracking

Research

Advertising

Education of students and/or other professionals

Check all that apply: I provide consent to Therapy Spot to take VIDEO of me and use it for: *

Therapy Progress tracking

Research

Advertising

Education of students and/or other professionals

Check all that apply: I provide consent to Therapy Spot to take AUDIO RECORDINGS of me and use it for: *

Therapy Progress tracking

Research

Advertising

Education of students and/or other professionals

Check all that apply: I provide consent to Therapy Spot to use: *

Prompt Oral Motor Prompting

Not applicable

I authorize Therapy Spot to be permitted to REVIEW AND OBTAIN copies of all hospital, medical, vocational and other related records concerning me and to discuss pertinent information with any professionals involved in my treatment. *

yes

no

I give permission for Therapy Spot to share my information both informally and via written reports with: *

I give permission to Therapy Spot for the following individuals to observe/participate in my therapy session for training purposes: *

I Consent to an Assessment at Therapy Spot

yes

no

I Consent to Treatment at Therapy Spot

yes

no

Please upload any documents you feel would be helpful for the therapist to read ahead of time

Drop a file here or click to upload Choose File

Maximum upload size: 33.55MB

My name below verifies that I have read, understood and have completed this form. I am consenting to all above checked fields and/or all fields with a response of "yes". *

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