Speak Up Speech Oregon | Ashley Johnson | Speech and Language Screening Permission Form

Date*
MM slash DD slash YYYY
Child's Name*
Date Of Birth / Age*
Child's Grade*
Teacher's Name*
Name of School*
Patient Gender*
- Female
- Male
Parents Names*
Language(s) Spoken in the Home*
Parent's Cell Number*
Email*
Has the child ever received speech language services (screening, evaluation, treatment)?
Check One*
- No
- Yes
If yes, please describe.*
Parent concerns regarding the child's speech and language skills and/or overall development:*
Consent*
I agree to the privacy policy.
Check here to give Speak Up Speech Therapy permission to complete the screening and share the results with the person whose contact information appears above. This signature also gives permission for Speak Up Speech to contact your child's teacher to discuss any speech and language concerns they may have.
Name*
Signature
Thank you,
Ashley Johnson, MS, CCC-SLP
Speak Up Speech Therapy
ashley@speakupspeechor.com
www.speakupspeechor.com
503-974-6774
Name
This field is for validation purposes and should be left unchanged.

Has the child ever received speech language services (screening, evaluation, treatment)?