Consent for Services

I consent to (please check all that apply):*
- 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.*
Full Name of Client
Signed:*
(Client/Parent/Guardian/POA)
Date*
Month
Day
Year