Learn It Philadelphia Speech (SLP) and Occupational Therapy (OT) Consent Form for Parents

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Email *

Child's Full Name

Child's Private School

Child's Grade Level

Child's Date of Birth

YYYY

Speech Therapy

I consent to have my child screened, evaluated, and if they qualify, participate in speech therapy.

I do not consent to have my child screened and participate in therapy.

Clear selection

Occupational Therapy (OT)

I consent to have my child screened, evaluated, and if they qualify, participate in OT.

I do not consent to have my child screened and participate in therapy.

Clear selection

I understand that if my child qualifies for services that the frequency of services my child receives is determined by school personnel. Further, I understand that services provided by Learn It are not bound by any Individual Education Plan (IEP) and should not replace special education services.

Yes

Clear selection

I understand that several people may be involved in the process to discuss my child’s goals and progress, including doctors, teachers, other therapists, or administration. I understand that my child may be grouped with other children of similar age and therapy goals. I understand that I will receive summaries and updates throughout the year regarding my child’s progress.

Yes

Clear selection

Parent/Guardian Initials:

Today's Date:

YYYY

Comments:

Please direct any questions to your school principal or administrator.

Parents, find us on the web! Click on the link below or scan the QR code.

http://bit.ly/learnitphilly

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