Speech Therapy Treatment Plan Agreement
Client Information
Client Name
Date of Birth
Parent/Guardian (if applicable)
Address
Phone
Email
Therapist Information
Therapist Name
Credentials
Treatment Plan
Goals
Treatment Methods
Session Frequency
Session Duration
Plan Review Date
Agreement & Consent
By signing below, I agree to the terms of the treatment plan and consent to speech therapy services as described above.
Client/Parent/Guardian Signature
Date
Therapist Signature
Date