On occasion, you may wish to have your Child brought to the Clinic by someone other than a parent. Please list the names of those individuals who have your permission to bring your child in for assessment and/or treatment. A day care worker of grandparent is an example of someone you would allow to bring your child in. If you do not want anyone to be authorized, please write NONE on the name line and sign at the bottom.
The Child listed in this packet may be brought in for assessment and treatment by the following individuals:
By signing below I also acknowledge that I received a copy of the Financial Policy and Summary of Notice of Privacy Practices.
Type your name to sign electronically