Speech Therapy Services Agreement and Consent for Treatment

Patient Information

Name: _________________________ Date of Birth: _________________ Parent/Guardian (if applicable): _________________________________

1. Consent for Treatment

I hereby authorize [Practice Name] and its licensed speech-language pathologists to provide speech therapy evaluation and treatment services.

2. Service Agreement Terms

Assessment and Treatment

• Initial evaluation to determine communication/swallowing status
• Development of individualized treatment plan
• Regular progress assessments
• Modification of treatment plans as needed

Financial Responsibilities

• Payment is due at time of service
• Insurance billing assistance provided when applicable
• Missed appointment fee: $_____ (if less than 24-hour notice)
• Current rate: $_____/session

Attendance Policy

• 24-hour cancellation notice required
• Three consecutive missed appointments may result in discharge
• Consistent attendance is essential for treatment success

Privacy and Records

• Treatment sessions are confidential per HIPAA regulations
• Records released only with written authorization
• Right to access treatment records upon request

3. Authorization

I acknowledge that I have read and understand this agreement. I accept responsibility for all charges related to treatment.

Signature: _________________________ Date: _________________

Clinician Signature: _________________ Date: _________________

4. Emergency Contact

Name: _________________________ Phone: _________________ Relationship: _________________________

[Practice Name Footer] Address: _________________________ Phone: _________________________ License #: _________________________