(the “Child”), hereby give a representative of The Loop Speech, Language, and Learning, LLC permission to evaluate the Child during a 15-minute speech/language/learning/occupational therapy screening. I understand that this screening is only a brief observation and although it is possible that speech, language, learning, or OT difficulties may be recognized during such an observation, a longer and more thorough evaluation is necessary to definitively diagnose such problems. Therefore, I agree that I will not hold The Loop Speech, Language, and Learning, LLC liable in the event a speech, language, learning, or OT difficulty is not recognized during this screening. I understand that recommendations will be made after this screening and the results of the screening will be discussed with me.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.