Parental Consent for Child Form

Parent Name *

First

Last

Parent Phone Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Child's Name *

First

Last

Child's Age

I give permission for my child to attend the session

Please note that a more effective outcome may be achieved if the child is not distracted by a parent being present.

During the RTT session I understand that there will be physical contact with my child and give permission for the therapist to:

Signature

Date / Time

Date

Time