Speech Therapy Services Informed Consent Form

Patient Information

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

Consent for Evaluation and Treatment

I, _________________________, hereby consent to speech therapy evaluation and treatment procedures to be performed by [Practice Name] and its qualified speech-language pathologists.

Authorization and Acknowledgments

1. Nature of Services

   • I understand that speech therapy may include assessment, diagnosis, and treatment of communication and/or swallowing disorders
   • Treatment may include exercises, strategies, and therapeutic activities
   • Services may be provided in-person or via telehealth when appropriate

2. Potential Risks and Benefits

   • Benefits may include improved communication skills, better swallowing function, and enhanced quality of life
   • Risks may include temporary discomfort, frustration during challenging tasks, or lack of improvement despite therapy

3. Financial Responsibility

   • I understand that I am responsible for all charges not covered by insurance
   • Cancellation policy: 24-hour notice required to avoid cancellation fees

4. Privacy and Confidentiality

   • I acknowledge receipt of the Notice of Privacy Practices
   • I understand that my protected health information will be used for treatment, payment, and healthcare operations

5. Patient Rights

   • Right to refuse treatment
   • Right to ask questions about procedures
   • Right to discontinue services at any time

Authorization Signatures

Patient/Guardian Signature: _________________ Date: _________

Speech-Language Pathologist: ________________ Date: _________

Witness

Witness Signature: _________________________ Date: _________