Consent for Services

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

205-534-4330

I authorize Leap of Language Inc. 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 Leap of Language Inc. in writing. In addition, Leap of Language Inc. may terminate services by notifying me in writing.

I do not give my consent or am withdrawing my consent regarding Jessica Mascarella rendering evaluation and therapy services to the client named below.

First Name

Last Name

Date of Birth

Legal Representative

Relationship to Client

Your Signature

Leap of Language Inc.

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37171 Sycamore Street Apt. 633, Newark, CA 94560

stcin001@gmail.com

205-534-4330

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Consent for Services