Skip to main content
Hit enter to search or ESC to close
Close Search
Menu
Home
About
Services
Forms
Resources
Developmental Charts
Glossary
FAQs
Testimonials
Privacy Policy
facebook
instagram
phone
C
o
n
t
a
c
t
U
s
Consent for Services
Please enable JavaScript in your browser to complete this form.
I authorize Branched Out Therapy, Inc. to render appropriate evaluation and/or therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Branched Out Therapy, Inc. in writing. In addition, Branched Out Therapy, Inc. may terminate services by notifying me in writing.
I do not give my consent or am withdrawing my consent regarding Branched Out Therapy, Inc. rendering evaluation and therapy services to the client named below.
Layout
Name of Client
*
Signature of Client or Legal Representative
*
Client Date of Birth
*
Relationship to Client
*
Submit
Close Menu
Home
About
Services
Forms
Resources
Developmental Charts
Glossary
FAQs
Testimonials
Privacy Policy
Contact Us
facebook
instagram
phone
Skip to content
Open toolbar
Accessibility Tools
Accessibility Tools
Increase Text
Increase Text
Decrease Text
Decrease Text
Grayscale
Grayscale
High Contrast
High Contrast
Negative Contrast
Negative Contrast
Light Background
Light Background
Links Underline
Links Underline
Readable Font
Readable Font
Reset
Reset