Consent for Evaluation & Treatment

I authorize ROSE Communication & Therapy Services to complete evaluation and provide speech-language therapy services.

Authorization

I authorize ROSE Communication & Therapy Services to complete evaluation and provide speech-language therapy services.

Client Name *Client / Guardian Name *

I understand that

Please confirm each statement

Therapy goals will be individualized based on evaluation results.Progress depends on consistent participation and collaboration.Therapy does not guarantee specific outcomes.I may ask questions regarding treatment recommendations.I may discontinue services at any time according to practice policies.

Signature

Client / Guardian Signature *Date *

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Every journey begins with hope.
Every bloom begins with ROSE.

Every bloom begins with ROSE.