Speech Therapy Services Consent and Communication Agreement

Patient Information

Name: ________________________________ Date of Birth: _________________________ MRN: _________________________________

Consent for Treatment

I, _____________________, hereby authorize [Practice Name] and its speech-language pathologists to provide speech therapy evaluation and treatment services to myself/my dependent. I understand that:

• Treatment may include oral-motor exercises, articulation therapy, language intervention, voice therapy, or other evidence-based therapeutic approaches
• Progress depends on multiple factors, including attendance, participation, and practice of recommended exercises
• Treatment protocols will be explained, and I have the right to question and refuse any procedures

Communication Authorization

I authorize the speech therapy team to communicate regarding my/my dependent's care via:

• Phone calls at: _____________________
• Text messages at: ___________________
• Email at: __________________________
• Patient portal messages

Information Sharing

I consent to the exchange of clinical information with:

• Primary care physician
• Other healthcare providers involved in care
• School personnel (if applicable)
• Insurance providers

Recording Authorization

• I authorize video/audio recording of sessions for clinical documentation
• I authorize recording for educational purposes
• I decline any recording

Acknowledgment

I have read and understand this consent form. I acknowledge that no guarantees have been made regarding treatment outcomes.

Signature: _____________________________ Date: _________________________________

Clinician Signature: _____________________ Date: _________________________________