Consent to Services

1
I authorize Louisville Therapy Group, PLLC to render appropriate evaluation and 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 Louisville Therapy Group in writing. In addition, Louisville Therapy Group may terminate services by notifying me in writing.
2
I do not give my consent or am withdrawing my consent regarding Louisville Therapy Group rendering evaluation and therapy services to the client named below.
3
Client Name* This field is required.
First Name
Last Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Signature of Client or Legal Representative* This field is required.
Clear
6
If Legal Representative, please describe relationship to client:
7
Date* This field is required.
Date
Month
Day
Year
8
Please verify that you are human* This field is required.
Should be Empty: