FORM NAME

DESCRIPTION

Parents First and Last Name *

Please check all that apply: I provide consent to Therapy Spot to take PHOTOGRAPHS of my child 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 my child 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 my child 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: *

Physical Prompting

Prompt Oral Motor Prompting

I provide consent to Therapy Spot to assist my child with toileting during: *

1 on 1 S-LP/BCBA/ABA Therapy at GABA School/At home/school or in clinic

I do not consent (not applicable)

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

yes

no

[if error] I give permission for Therapy Spot to share my child's information both informally and via written reports with: *

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

I consent to an Assessment at Therapy Spot for my child

yes

no

I consent to Treatment at Therapy Spot for my child

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". *

Uploading Files. Please Wait.