Clinique Mots et Gestes-Create Account

​Services Request

Home > ​Services Request

​Services Request


Please Enter Valid Email Address

Type of consultation

Type of problem


File Name :

+ Add more


Authorization :

​I authorize the Speech-Language Pathologist to perform all tests, examinations, treatments and audio and video recordings necessary to complete his or her mandate of service, all of which are kept in the client's file in accordance with current professional standards. I also authorize the speech-language pathologist to use my email address to open my account on this client portal, a secure and encrypted website protected by an SSL certificate. This portal is an internet exchange tool on which we will post all documents related to speech and language therapy assessment and treatment (reports, notes, therapeutic exercises, etc.) accessible by you only with your user name and password.

Teaching and Research (optional):

​I authorize the Speech and Language Pathologist to use, non-nominatively (without any possibility to identify whose data this is) speech, language, voice, academic skill or neurolinguistic information, as well as audio or video recordings taken during assessment or therapy, for teaching or research. This authorization is valid for the time there is active assessment or therapy, and until client file data is destroyed according to regulations, five years after the last service date. If data is to be used, your Speech and Language Pathologist will be contact you to explain the context in which your data could be used, and obtain again your consent in this specific context. This consent may be revoked at any time

Would you like us to inform another professional (medical doctor, specialist. school personnel. etc) about our assessment results and recommendations? Please indicate above the name of the professional and how to reach them. This request also is a consent to exchange information with mentioned professional.