Authorization Form

Authorization Form

I hereby give permission for a speech and language evaluation to be performed at the Santa Rosa RiteCare® Childhood Language Center. I understand the purpose of this evaluation is to determine the nature and extend of my child’s speech/literacy and/or language difficulties. This evaluation will be performed by a certified, licensed speech-language pathologist. All reports regarding this evaluation will be confidential and remain in the Center files unless otherwise requested by me.

I hereby give permission for speech-language therapy to be provided to my child at the Santa Rosa RiteCare® Childhood Language Center. This therapy shall be provided by a certified, licensed speech-language pathologist or a graduate student clinician who is under the supervision of a certified licensed speech-language pathologist.

Signature:

Date:

Relationship to Client:

Client’s Name: