psls_Permission_Feeding

Permission to Evaluate (if applicable)
I give permission for Pediatric Speech and Language Services (PSLS) to evaluate my child for speech, language, auditory, swallowing, and/or oral motor skills. This evaluation will determine the need for further intervention.
Child's Name
Parent Signature

Clear
Date

MonthDayYear
Date
Feeding Therapy- Release of Liability (if applicable)
I give permission for Pediatric Speech and Language Services (PSLS) to provide oral motor/feeding therapy to my child. I understand that the goal of feeding therapy is to get my child to tolerate a wider variety of flavors and textures of foods as well as to manage that food successfully as it passes the lips, is chewed, and is swallowed by my child.

Although my child’s therapist will discuss with me the plan for feeding therapy, I release PSLS from liability should my child have an adverse reaction to any new food that is introduced. If necessary I will administer first aid to my child and call 911 if needed.
My child has known allergies to/should not be fed the following food(s):
Child's Name
Parent Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Permission to Evaluate (if applicable)