Speak Up Speech Oregon | Ashley Johnson | Informed Consent for Speech Therapy

Parent / Legal Guardian Name*
First Last
Child's Name*
First Last
Informed Consent for Speech Therapy*
- I hereby request and consent to Speak Up Speech Therapy, LLC to perform treatment and care for my child as prescribed by a physician and/or recommended by a speech-language pathologist. I understand and am informed that, as in the practice of medicine, speech language and feeding therapy may have some risks. I understand that I have the right to ask about these risks and have any questions answered about my child’s condition, prior to treatment. I acknowledge and agree that a parent or legal guardian must be present during each treatment session (in the home, in the treatment room, and/or in the waiting room). I have carefully read and fully understand this Informed Consent Form and have had the opportunity to discuss it with the treating therapist. I consent and authorize Speak Up Speech Therapy, LLC to administer treatment under the direction and supervision of a certified speech-language pathologist.
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Date*
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