Informed Consent and Treatment Form

w. speechlanguagecorner.com p. 704.626.7727 f. 704.626.7727 e. speechlanguagecorner@gmail.com
Informed Consent and Treatment Form
You would like or your child First Name Last Name is being recommended for a screening and/or speech/language evaluation (if needed). The Speech & Language Corner, PLLC, will provide free speech/language services to children with Medicaid.
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Does your child have Medicaid?

YesNo
Does child have NC Health Choice?

YesNo
Medicaid/Insurance ID Number:
Child’s primary care doctor or Group:
Parent/Legal Guardian Name:

First NameLast Name
Parent Street Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent(s)/Legal Guardian Phone # (Required):*

Area CodePhone Number
Email
example@example.com
Today’s Date:

MonthDayYear
Date
If you also want your child to receive treatment after the screening, indicate & sign below
First Name Last Name I hereby give my permission for The Speech & Language Corner, PLLC to conduct a speech language screening and/or evaluation, and if eligible for needed treatment (i.e., speech/language therapy, consultation). This consent provides the Speech & Language Corner, PLLC with the authority to bill my Medicaid insurance for all therapy services provided. The signed consent also gives the Speech & Language Corner, PLLC the permission to exchange and share information pertinent to the student to/from the therapist and the child’s primary care physician group. If the child qualifies for therapy then services will occur during the school day.

Signature of Patient/Parent Legal Guardian or Other Legally Responsible Person
Signature*

Clear
Thank you for the opportunity to serve your child. Please return this form to the teacher within 2 days. The Speech & Language Corner, PLLC will pick it up from the teacher/center.
Sincerely

Dr. Tonya Dixon-Thompson., M.Ed. CCC-SLP/PhD
Should be Empty:

Informed Consent and Treatment Form

Sincerely