Informed Consent for Speech-Language Evaluation & Consent to Release Records

Thank you for your interest in services through Pencil and Pathways. Please review the information below regarding the nature of services, your rights, and our obligations. Your signature at the end of this form will indicate your informed consent to proceed.

Explanation of Services

Speech-Language Pathologists (SLPs) provide evaluation and consultation services to support students’ communication development and academic success.

SLPs are licensed by the Texas Department of Licensing and Regulation (TDLR) and may also hold certification from the American Speech-Language-Hearing Association (ASHA).

Speech-language services may focus on areas such as speech sound production, language development, social communication, voice, fluency, and other communication skills that impact educational functioning.

SLPs work collaboratively with families, educators, and other professionals to better understand a student’s communication strengths and needs and to develop appropriate recommendations.

Reason for Referral

The student is being referred for evaluation or consultation by school personnel and/or a parent/guardian due to concerns related to communication development, which may include:

  • Speech sound production (articulation or phonology)

  • Expressive language (using words, sentences, and grammar)

  • Receptive language (understanding spoken language)

  • Social/pragmatic communication

  • Fluency (stuttering)

  • Voice quality

  • Other communication concerns affecting participation in school or learning environments

The purpose of the evaluation is to determine whether communication difficulties may be impacting the student's functioning and whether further supports or services may be recommended.

Nature and Purpose of Proposed Services

A speech-language evaluation may include one or more of the following procedures:

  • Clinical interviews with parents, teachers, or other relevant adults

  • Review of educational or developmental records

  • Observation of the student in an educational setting

  • Standardized speech-language assessments

  • Informal language and communication tasks

  • Speech sound analysis

  • Rating scales or questionnaires

  • Interaction with the student through structured tasks or conversation

Information gathered from these procedures will be integrated into a written report.

You will receive a copy of the evaluation report and an opportunity to review and discuss the results.

Purpose/Goals of Services

The evaluation is designed to:

  • Identify the student’s communication strengths and areas of need

  • Determine whether speech-language difficulties may be present

  • Clarify how communication skills may be impacting learning or participation

  • Provide recommendations to support communication development

  • Assist school teams and families in planning appropriate interventions or supports

Confidentiality

Pencil and Pathways is committed to protecting the confidentiality of all client information.

Information shared during services will be protected in accordance with applicable laws and professional standards, including:

  • HIPAA, where applicable

  • FERPA, when services are provided in educational settings

  • Texas laws governing confidentiality of records

  • Professional ethics and licensing requirements for speech-language pathologists

Information may be shared with relevant school personnel or collaborating professionals when necessary to support the student’s educational needs. Identifying information will be limited to what is necessary for consultation and service planning.

Confidential information may be disclosed without consent only in situations required by law, such as:

  • Suspected abuse or neglect

  • Risk of harm to self or others

  • Court orders or legal requirements

Records and Documentation

Records related to evaluation services are stored securely and maintained in accordance with applicable laws and professional standards.

Documentation may include:

  • Evaluation protocols

  • Interview notes

  • Observation summaries

  • Written evaluation reports

Records are retained for the time period required by law and professional guidelines.

Parents or guardians may request copies of records in writing.

Voluntary Participation

Participation in speech-language evaluation services is voluntary. You may withdraw consent at any time in writing.

If there are significant changes to the nature or scope of services, updated consent may be requested.

Your Consent

By signing below, you acknowledge that:

  • You have read and understood the information provided above.

  • You have had the opportunity to ask questions.

  • You voluntarily consent for a Speech-Language Pathologist with Pencil & Pathways to conduct the evaluation described above.

  • You consent to the collection and use of relevant information for the purposes of evaluation and consultation.