Speech & Language History Form

All fields marked with * are required.

Please fill out this form to the best of your ability. If you have any questions, please call us at 910-673-5437.

Patient Information

Dear Parents and Families:

We are required by the governing board for Speech Language Pathology to inform our clients if a Speech Language Pathology Assistant may be working with your child. This letter is to inform all our clients and their families that your child’s speech and language services may be provided by a Speech Language Pathologist Assistant. All our Assistants have completed an accredited two-year Speech Language Pathology Assistant college program and are registered with the NC Board of Speech Language Pathology. All SLPA’s are closely supervised by a licensed Speech Language Pathologist. Please sign this form below for inclusion into your child’s records. Feel free to contact us at our office should you have any questions or concerns at the above listed phone number. I have read and acknowledge the above listed information.