RELEASE AND AGREEMENT

Client name
Date
Address
Phone
City and Zip
Client Birth Date
Parent or Guardian
   
Address
    
City and Zip
    


My signature upon this form indicates that I understand and agree to the following conditions:

  • I grant permission to The Center for Stuttering Therapy to provide appropriate therapy services to the above-mentioned client.
  • I grant permission to take above-mentioned client outside the building for appropriate transfer sessions. I release The Center for Stuttering Therapy from responsibility in case of accident or injury during these outside transfer therapy sessions.
  • I release The Center for Stuttering Therapy from responsibility in case of illness or injury of any kind to the above-mentioned client during travel to or from and during attendance at The Center for Stuttering Therapy.
  • I grant permission to exchange information, including progress reports, about the above-mentioned client to individuals or agencies listed below:

    Agency
    Address
    Agency
    Address
    Agency
    Address



or print out & fax to: 303-527-0756 (Please call first 303-530-9191)
or mail to CST

Signed ______________________________________ Date ______________