Adult Consent and Treatment Form

w. speechlanguagecorner.com p. 704.626.7727 f. 704.626.7727 e. speechlanguagecorner@gmail.com
Adult Consent and Treatment Form
I First Name Last Name would like to be screened and/or evaluated (if needed) by the Speech & Language Corner, PLLC.
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Does you have insurance?

Yes No
Insurance Provider Name
Insurance ID Number:
Primary care doctor or Group:
Home Address:

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
Today’s Date:

Month Day Year
Date
If you also want to receive treatment after the screening, indicate & sign below
I First Name Last Name 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.
Signature *

Clear
Thank you for the opportunity to serve you.
Sincerely

Dr. Tonya Dixon-Thompson., M.Ed. CCC-SLP/PhD
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