Small Talk

Acknowledgment That You Have Received Our HIPAA Privacy Notice

Small Talk Speech and Language Therapy, Inc. is required by law to keep your health

information safe. This information may include:

● notes from your doctor, teacher, or other healthcare provider

● your medical history

● your test results

● treatment notes

● insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared. It also tells you how you can look at and comment on your information.

By signing this page, you are saying that you have reviewed and been offered a copy of our privacy notice.

Signature

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Print Patient’s Name

Date

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Patient or Spouse/Guardian Signature

Relationship to Patient

Consent for Services Provided by a Speech-Language Pathology (SLP) Aide

Client Name:

Date of Birth

Month

Day

Year

Dear Parent/Guardian,

This notice is to inform you that some of the speech-language services provided to your child at Small Talk Speech Therapy may be administered by a Speech-Language Pathology Aide (SLP Aide). SLP Aides are trained support personnel who work under the direct supervision of a licensed Speech-Language Pathologist (SLP), as required by state regulations and professional standards.

Please be assured that the supervising SLP remains fully responsible for your child’s evaluation, treatment planning, and ongoing supervision of the SLP Aide. All services are designed to maintain the highest level of quality and care.

By signing this form, you acknowledge that:

- You have been informed of the role of the SLP Aide.

- You understand that all services will be supervised by a licensed SLP.

- You give your consent for your child to receive services delivered in part by an SLP Aide.

If you have any questions or would like more information, please don’t hesitate to contact us.

Parent/Guardian Name (Print):

Signature (Parent/Guardian):

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Date

Month

Day

Year

Supervising SLP Name (Print):

Signature (Supervising SLP):

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Date

Month

Day

Year

SLP Aide Name (Print):

Signature

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Date

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Year

Acknowledgment That You Have Received Our HIPAA Privacy Notice

Consent for Services Provided by a Speech-Language Pathology (SLP) Aide

Child Case History Form Small Talk Speech Therapy