Speech Therapy Authorization for Treatment Form

Patient Information

Patient Name: _________________________ Date of Birth: _____________ Parent/Guardian (if applicable): ______________________________________

Consent for Treatment

I, the undersigned, hereby authorize [Practice Name] and its speech-language pathologists to perform speech, language, voice, fluency, and/or swallowing evaluations and treatment as prescribed by my physician and/or recommended by my speech-language pathologist.

Authorization Details

1. I understand that I have the right to:

   • Ask questions about my treatment at any time
   • Decline services at any time
   • Be informed of the evaluation results and treatment recommendations
   • Receive information about alternative treatment options

2. I acknowledge that:

   • Treatment outcomes cannot be guaranteed
   • Regular attendance is essential for optimal progress
   • Home practice activities may be assigned
   • My active participation is necessary for success

Financial Agreement

I understand that I am responsible for:

• Payment of all charges not covered by insurance
• Providing current insurance information
• Notifying the clinic of any changes in insurance coverage
• Cancellation fees for appointments not canceled with 24-hour notice

Privacy Notice

I acknowledge receipt of the Notice of Privacy Practices and understand that my protected health information may be used by the practice as described in the notice.

Signatures

Patient/Guardian Signature: _________________________ Date: _________

Witness Signature: _________________________________ Date: _________

SLP Signature: ____________________________________ Date: _________