For the duration of therapy services provided by Cowtown Pediatrix Clinic (CPC), I give permission for the staff occupational/speech therapists at CPC to evaluate and treat my child as well as provide Caregiver Training.  When OT/ST interns are rotating through CPC, I understand that my child may be evaluated and treated by an OT/ST intern. I understand that my child’s clinical needs will always be under the supervision of a licensed OTR/SLP from CPC. I also understand that the level of independence the OT/ST intern has with my child is directly related to his/her level of clinical development within his/her fieldwork experience. In addition, I understand, while CPC strives to be consistent, that due to availability in the schedule, the therapist that performs the evaluation may not necessarily be my child’s ongoing therapist.

HIPPA: I understand that all information surrounding my child is private and confidential.  I also give permission for email correspondence with CPC regarding my child.

I authorize CPC to discuss my child’s care, if applicable, with other team members, from outside agencies such as doctors, schools or other therapists.

I authorize CPC to use my child’s photo(s) and/or audio recording for digital marketing purposes and/or for clinical educational training