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920 West Chester Pike 1489 Baltimore Pike 709 E. Gay Street Havertown, PA 19083 Bldg. 200, Suite 250 West Chester, PA 19380 Springfield, PA 19064 Telephone: 610-544-2110 Fax: 610-604-9510 Parental Consent Form I have been informed that a request has been made for my child/ren named below to receive treatment from Associates of Springfield Psychological. My signature indicates that I give my consent for my child to receive such services. I understand that I can contact Associates of Springfield Psychological to discuss how I may become involved in these services, as well as to learn more about the specific nature of the services to be provided.
Signature of Parent Date
Signature of Parent Date
Name of Child |