Authorization for Therapy Session

  • I hereby authorize Children’s Therapy Services to perform a free developmental screening for Occupational, Physical and Speech therapy skills.

    Date of Service: This screen will take place at Little Owl’s Daycare and Preschool in the month following signing this sheet during the child’s regularly scheduled hours.

    Fee: This is a free screening that is a complimentary service provided by Little Owl’s Daycare and Preschool.

    I understand that my authorization will remain effective from the date of my signature until 1 year following, and that the information will be handled confidentially in compliance with all applicable federal laws.

    I understand that I will receive a copy of the recommendation following the day it was performed. This information will only be shared with the family and potentially the teachers at Little Owl’s Daycare and Preschool for it will be a handout in written form. I also understand that I may revoke the authorization at any time by written, dated communication.

    I have read and understand the nature of this release.
  • Date Format: MM slash DD slash YYYY