Basic Information

Other Information

Type of consultation

Type Of Problem

Parental Authority

Other Information

I authorize the Speech and Language Pathologist to use speech, language, voice or academic skills information, as well as audio or video recordings collected during assessment and treatment for teaching or research puposes.

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.