Forms for Services
Forms are in .pdf format to be printed, signed, and returned.  They can be returned in person, via email, or scanned and sent as image files via text messages.
Notice of Privacy Practices
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used.Â
Please keep this form for your records.
Acknowledgment of Privacy Practices
Please sign and return this form to acknowledge you have received the Notice of Privacy Practices.
HIPAA Release
Please complete and sign form to indicate individuals/institutions that the Speech Language Pathologist can communicate with regarding your child's evaluation and treatment.
Informed Consent
Please sign and return to indicate your approval for the initiation of services.
Fees Agreement
Please sign and return to acknowledge an agreement regarding fees and method of accepted payments.
