Client Name:

      Date of Birth:

          Age:

    Patient's Status:

    Street Address:

State & Zip Code:

     Email Address:

 Guardian's Name:

             Employer:

     Phone Number:

 Alternate Number:

        School Name:

    Teacher's Name:

Teacher's Phone # :

      Funding Source/
       Insurance Type:

       Policy Number:

Guardian's Signature:  Submission of this form is deemed an electronic signature of the guardian. I give Powell and Associates Comprehensive Educational Services permission to screen my child for speech and language concerns.  I also give permission to PACES to file a claim with my child's insurance carrier for compensation for this service. I have read and agree with the above statements.

Agree:                        Disagree: