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Home
Services
Adult Services
Swallowing Disorders or Dysphagia
Post-Stroke Rehabilitation
Cognitive-Communication Disorders
Accent Reduction/Modification
Voice Disorders
Pediatric Services
Speech And Language Therapy
Occupational Therapy
Feeding Therapy
Reading/Dyslexia, Auditory Processing, And Listening Skills
Social Skills Groups
Early Intervention
About Us
Our Team
Our Treatment Approach
Forms
Blog
Contact
Treatment Authorization
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/ Treatment Authorization
I, (Parent/Guardian named below) authorize Chandler Speech and Language Services, LLC to evaluate and provide the recommended speech and language therapy to the patient named below.
Therapy/treatment is contingent upon the results of the evaluation and the recommendations of the speech and language pathologist.
Prior to evaluation a prescription must be obtained.
Parent/Guardian
*
First
Last
Patient's Name
*
First
Last
Patient of Parent/Guardian Signature
*
Relationship to Patient
*
Today's Date
*
Date Format: MM slash DD slash YYYY
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