I hereby request and consent to speech therapy services provided by Speak Up Speech Therapy, LLC for my child. Services may include evaluation, treatment, and care as recommended by a licensed speech-language pathologist and/or prescribed by a physician.

I understand that, as with medical and other therapeutic services, speech, language, and feeding therapy may carry some risks. I have the right to be informed of these risks, to ask questions, and to receive clear answers about my child’s condition and treatment before therapy begins.

I acknowledge that a parent or legal guardian must remain present during sessions held in the home or clinic setting (whether in the treatment room or waiting area). I further understand that when services are provided in the school setting, a parent or legal guardian is not required to be present.

I confirm that I have read and fully understand this informed consent form and that I have had the opportunity to discuss it with the treating therapist. By signing below, I consent to and authorize Speak Up Speech Therapy, LLC to provide treatment in the home, clinic, and/or school setting under the direction and supervision of a certified speech-language pathologist.