Consent to Screen – Sage Speech & Language

Free Speech & Language Screening for Your Child

Takes about 2 minutes to submit • No diagnosis • No obligation
Speech-Language Screening Information

This form gives permission for a brief, no-cost speech screening at your child’s daycare. The screening identifies communication strengths and possible areas of concern. It is not a full evaluation.
Child’s Full Name*

First NameLast Name
Child’s Date of Birth*

MonthDayYear
Date
Learning Center Name*
Child’s Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Legal Guardian Full Name

First NameLast Name
Relationship to Child*
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email Address*
example@example.com
Does your child have Medicaid?*

YesNo
Do you have any speech and language concerns?
If speech therapy is recommended, I would like more information about on-site services at my child’s daycare.
Date Signed*

MonthDayYear
Date
Electronic Signature Authorization: *
By typing my full legal name above, I acknowledge that I am the parent or legal guardian of the child listed above. I understand that my typed name serves as my electronic signature and confirms my consent for my child to participate in a speech-language screening conducted by Sage Speech & Language.
HIPAA & Consent Information

By submitting this form, you give permission for your child to participate in a brief speech-language screening conducted by Sage Speech & Language. This screening is not a full evaluation. Information collected will remain confidential and results will be shared directly with you.
Should be Empty:

Free Speech & Language Screening for Your Child

Speech-Language Screening Information

HIPAA & Consent Information