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Client forms

Thank you for considering services from Alexander Speech and Hearing. We look forward to working with you:

Evaluation Documents

Below are the forms that must be completed prior to an evaluation being conducted.

Child Intake/History


This form helps guide the evaluation process by providing background information on the client such as any medical concerns, previous evaluations, previous therapy, and parent's concerns.


The Notice of Privacy Practices states the responsibilities of Alexander Speech and Hearing, the uses and disclosures of protected health information as well as the patient's rights to privacy. The Acknowledgement of Receiving the HIPAA Form is a form for the client to sign that acknowledges that they have seen the HIPAA notice and understand its contents.

Consent to Treat:


This form gives permission for Alexander Speech and Hearing to complete an evaluation and render appropriate therapy services.

Payment Policy:


The Payment Policy and Fee Schedule details the rates, services we provide and explains the client's financial responsibility and payment options and terms. Think of this as the legal “menu” of offerings and the price associated with each service.

Communication Preference:


This form allows you to indicate the manner in which you prefer to receive communication from Alexander Speech and Hearing. Options include phone calls, text messages, email, "snail mail" etc.

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