• 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         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.

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    Pick a Date
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    Pick a Date
  • If you also want your child to receive treatment after the screening, indicate & sign below
  •       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 

  • 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
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