Informed consent for speech-language pathology services for a minor child, covering evaluation, treatment goals, session structure, and parent participation. Parent/guardian signer.
The Speech-Language Pathology Evaluation & Treatment Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (parent) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, healthcare, speech therapy, pediatric, parent guardian. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Speech-Language Pathology Evaluation & Treatment Consent > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Practice / Clinic Name:** ___________ **Speech-Language Pathologist (SLP):** ___________ **License Number:** ___________ **Child's Name:** ___________ ("Child") **Child's Date of Birth:** ___________ **Parent / Legal Guardian Name:** ___________ ("Parent/Guardian") **Relationship to Child:** ___________ --- ## 1. Purpose of Evaluation and Services (a) The Parent/Guardian consents to a comprehensive speech-language pathology evaluation of the Child and, upon agreement of the resulting treatment plan, to ongoing speech-language therapy services as recommended by the SLP. (b) The evaluation may include standardized and non-standardized assessments of: **Primary Areas of Concern (check all that apply):** Articulation / Speech Sound Disorders: ___________ Language (receptive / expressive): ___________ Fluency (stuttering / cluttering): ___________ Voice / Resonance: ___________ Pragmatic / Social Communication: ___________