(Parent/Legal Guardian/Patient), consent to the provision of speech-language pathology and/or occupational therapy evaluation and treatment services provided through Michele D. Shieldes, PLLC / Innovative Therapy Group.
Services may be provided by licensed Speech-Language Pathologists (SLP), Speech-Language Pathologist Assistants (SLPA) under required supervision, Speech-Language Pathologist Interns/Graduate Student Clinicians/Clinical Fellows under required supervision, Licensed Occupational Therapists (OTR), and Occupational Therapy Assistants (OTA) under required supervision, in accordance with Texas law.
Services may include evaluation, assessment, treatment planning, therapeutic intervention, caregiver education, and related services within the scope of speech-language pathology and/or occupational therapy practice. The type, frequency, duration, and goals of therapy will be determined based on clinical evaluation and may be modified as clinically appropriate.
Therapy services are generally low risk; however, potential risks may include fatigue, muscle soreness, sensory overstimulation, frustration, or temporary regression as new skills are introduced. No guarantees have been made regarding outcomes.
Telehealth services may be provided when clinically appropriate. Telehealth involves electronic communication technology and may carry risks such as technical interruption. I may withdraw consent to telehealth services at any time by providing written notice.
If the patient is a minor, I certify that I am the legal parent or guardian and have authority to consent to services.
I acknowledge that I have had the opportunity to ask questions and that my questions have been answered. I voluntarily consent to speech-language pathology and/or occupational therapy services.
