Assessment Consent Form
By completing this form you give permission to Maria Bernabe, M.S., CCC-SLP, Certified Speech Pathologist, to complete a speech and language assessment for your child.
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Parent’s name: *
Phone number: *
Child’s name: *
Child's date of birth: *
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By writing your name below, you give Maria Bernabe, M.S., CCC-SLP permission to complete a speech-language assessment for your child. *
By checking "I agree" below, I understand that payment is due in full at the time of the evaluation. *
Required
Date of consent: *
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This form was created inside of Toddler SLP.