ShowMe Therapy Services Informed Consent for one or mutliple of the following services: -Physical Therapy -Occupational Therapy -Speech-Language Therapy -Myofunctional Therapy -Behavior Therapy -Feeding Therapy -Reading Intervention -Academic Evaluation and/or Tutoring I hereby request and consent to ShowMe Therapy Services to perform evaluation, treatment, and care for my child as recommended by a licensed provider. I understand and am informed that, as in the practice of medicine, therapy may have some risks. I understand that I have the right to ask about these risks and have any questions answered about my child’s condition prior to treatment. I acknowledge and agree that a parent or legal guardian must remain in the building during each treatment session. I understand that all service payments are due at the time of service. If a super bill is provided, this is not a guarantee of insurance coverage, rather a detailed receipt that you may utilize to seek possible reimbursement from insurance. This is provided as a courtesy by ShowMe Therapy Services. I understand that a graduate student of physical or occupational therapy or speech-language pathology may participate in my child’s care at any time, under the supervision of a licensed therapist. In addition, other students may be present for observation as part of a job shadow program. I have carefully read and fully understand this Informed Consent Form and have had the opportunity to discuss it with a member of ShowMe Therapy Services if I chose. I agree to hold ShowMe Therapy Services harmless for claims or damages in connection with treatment. This is a contract between myself and ShowMe Therapy Services, and I understand that it is also a release of potential liability. By typing your full name in the space below you are certify that you are the legal guardian of the participant and agree to the terms listed above.