• w. speechlanguagecorner.com     p. 704.626.7727     f. 704.626.7727     e. speechlanguagecorner@gmail.com

  • Adult Consent and Treatment Form

  • I         would like to be screened and/or evaluated (if needed) by the Speech & Language Corner, PLLC.

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    Pick a Date
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    Pick a Date
  • If you also want 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 client to/from the therapist and the client’s primary care physician group.

  • Clear
  • Thank you for the opportunity to serve you.
  • Sincerely

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