Speech Therapy Services Agreement and Contract

This agreement is made between [Practice Name] ("Provider") and [Patient Name/Guardian] ("Client") on [Date].

1. Services

The Provider agrees to provide the following speech therapy services:

• Initial evaluation and assessment
• Development of individualized treatment plan
• Regular therapy sessions as scheduled
• Progress documentation and reporting
• Home exercise program development

2. Schedule and Attendance

Session Duration

• Each therapy session will last [X] minutes
• Sessions will occur [frequency] per week

Cancellation Policy

• 24-hour notice required for cancellations
• Late cancellations/no-shows may be billed at [rate]
• Three consecutive no-shows may result in discharge

3. Financial Agreement

Fees and Payment

• Evaluation fee: $[amount]
• Per session fee: $[amount]
• Insurance billing services: [details]

Payment Terms

• Payment due at time of service
• Accepted payment methods: [list methods]
• Insurance copayments required at check-in

4. Privacy and Records

• HIPAA compliance assured
• Treatment records maintained confidentially
• Release of information requires written consent

5. Consent for Treatment

I authorize speech therapy evaluation and treatment and acknowledge:

• Risks and benefits explained
• Right to refuse treatment
• Participation requirements

Signatures

Provider: _________________ Date: _______

Client/Guardian: ____________ Date: _______

[Practice Contact Information]