Teacher's Name *

First Name

Last Name

Child's Full Name *

First Name

Last Name

Date of Birth *

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DD

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Parent/Guardian 1 *

First Name

Last Name

Parent/Guardian 2

First Name

Last Name

Parent Phone Number *

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I give consent for my child to receive speech-language pathology services from Michelle Thompson, Speech-Language Pathologist. I give consent for test results, treatment goals, sessions notes, and clinical reports to be shared with my child’s classroom teacher(s) and administrators. *

By checking this box you consent to the above.