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I consent to (please check all that apply):
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A Pediatric Speech Assessment with Report
A Pediatric Language Assessment with Report
A Pediatric Social Language Assessment with Report
An Adult Speech and Language Evaluation Session
Parent Training Sessions
Speech-Language Therapy Sessions
I give permission for the individual named below to be assessed and/or treated by Lisa Cytrynbaum.
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Full Name of Client
Signed:
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(Client/Parent/Guardian/POA)
Date
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Day
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