Initial Speech-Language Evaluation Consent Form

Initial Speech-Language Evaluation Consent Form

A comprehensive evaluation using one or more formal assessments to measure your child’s communication skills across one or more areas (e.g., expressive language, articulation, and/or pragmatics).
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age *
DURATION: 1 to 2 hours.

MEASURES: Informal (professional observation, parent/teacher consultation, checklists) and/or formal assessment tools (standardized tests, criterion-referenced tests).

OUTCOME: A comprehensive evaluation report delivered electronically, with a detailed description of child’s developmental background, health history, observations, assessment results, and clinical recommendations.

COST:
- Stuttering/Fluency Evaluation (92521) - $250
- Articulation/Phonology Evaluation (92522) - $250
- Comprehensive Speech-Language Evaluation (92523) - $350
- If using insurance, an estimated allowable rate will be provided by your therapist.
Iparent name* hereby give consent to Talk Play Learn Speech Therapy to evaluate my child as indicated above.
Signature *

Clear
Please enter the email where you would like to receive a password-protected copy of this form. Please note down the password for your records: 1TPLspeech!
example@example.com
Should be Empty: