Client Intake Form (Child)

Client Intake Form (Adult)

Policies & Procedures

Release of Information

Video Consent Form

Video Consent Form

You have two options for filling out the form:

1) Scroll down and fill in the form online and submit.

2) View, download, print, handwrite your responses and bring to your first meeting with Lucia Reardon.

Download Video Release Form

Please note that Lucia Reardon Speech Language Pathology, LLC does not accept payment through insurance companies. Clients are provided with a monthly bill that may be submitted to their health insurance, if appropriate.

Clients must read, understand and agree to the terms and conditions in the Policies and Procedures of Lucia Reardon Speech Language Pathology, LLC. Clients will be provided with a printed copy and agree to be responsible for the payment for speech and language therapy treatment, evaluation and consultation services rendered as outlined to commence and receive services.

This form will be printed out at the time of the first consultation. The parent/guardian/client will sign and date it and the form will be retained in the client’s file.

Video Consent Form

* Required information

Video/Image Release Form

Child's Name(Required)
Child's Name*
I agree to allow photographs or videotapes to be taken of my child for (check all that apply):
I agree to allow photographs or videotapes to be taken of my child for (check all that apply):
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.