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SPEECH LANGUAGE PATHOLOGY
SCREENING & ASSESSMENT CONSENT FORM
School:
*
Teacher's Name
*
First Name
Last Name
Child's Full Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
Parent Email
*
Parent Phone Number
*
(###)
###
####
Background Information
My child has been seen by a speech-language pathologist
YES
NO
My child's first language is:
Country of Birth:
*
Please list any additional questions or concerns:
Consent:
I give consent for my child to participate in a speech-language screening and/or assessment with Michelle Thompson, Speech-Language Pathologist. I give consent for the screening and/or assessment results to be shared with my child’s classroom teacher and school administrators.
*
By checking this box you consent to the above.
Follow Up:
Please note that you will receive a follow-up email regarding the speech-language screening results. If your child requires further assessment, you will be contacted by phone.
Thank you! Michelle will be in touch with you at her earliest convenience.
