AUTHORIZATION FOR ASSESSMENT

I give my permission for my child to be evaluated and assessed by A Piece of the Puzzle Behavioral Interventions LLC to determine initial and continuing eligibility for services. I understand that this information will also be used to identify my child’s strengths and needs to provide appropriate intervention services and programming.

CHILD'S FULL NAME:

DOB:

PARENT NAME:

DATE:

PARENT/GUARDIAN SIGNATURE:

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I accept that this is the legal representation of my signature.