SPEECHIE / Centre for Speech-Language Therapy
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YOUR CART
Consent Form
Consent is an ongoing process and is an on-going conversation. You will see us asking for permission before we do many activities and before we share any personal information with other people. We invite you to speak up at anytime. Before we start, we want to make sure that everyone's expectations are clear. You can review all of our policies
here
.
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Indicates required field
Your name and relationship to the client
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Client name and date of birth
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Best way to get in touch with you
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Email address(es) of any other people you would like us to include in our communications
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Description of our services
All our work is strongly grounded in research and evidence. We explain as we go and we keep you informed. The details of assessment and treatment will evolve as we go along, and activities may include:
Play (for children)
Informal conversations, observations, and assessment probes
Gathering information from you and significant others via checklists and interview
Developing assessment plans and treatment goals together
Formal screening and testing procedures as discussed and agreed
Collection of speech, language, reading, or writing samples
Activities for establishing, consolidating, and transferring new communication skills
Use of communication apps and other assistive technology and visual supports to support communication autonomy
I consent to Speechie providing speech-language therapy services which may include advice & guidance, assessment, diagnosis, treatment, organising assistive technology trials, and consultation with those you give us permission to contact.
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Yes, I agree
No, please call me to discuss further
Photos, videos, and audio recording
Visual and audio recording is an important tool for assessment, progress tracking, communicating with families / schools, and during therapy. It is impossible to fully analyse language and communication skills in the moment. Recordings are essential for us to complete some assessment tasks.
We only capture positive moments and always ask client permission before hand.
We store all electronic media on secure devices and cloud-based services using encrypted tools whenever possible and with password-only access. Clients and approved caregivers / parents can request a copy or link to the recordings at any time.
From time to time, we provide training to schools and other agencies. Recordings can be a powerful way to illustrate key concepts and advance our collective knowledge on how to be a more inclusive and neurodiversity affirmative society. We may contact you to see if you would give permission for a specific recording to be used in a training context. This is optional and you always have the right to decline.
Do you consent to videos, photos, and audio recordings being recorded and used as described above?
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Yes
No
Other
If other, please explain:
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Information sharing and storage
We abide by the Privacy Act of 2020 and the Health Information Privacy Code of 2020. We strive to uphold the dignity and privacy of our clients and their families at all times.
We only collect information from families and clients directly or from other people or agencies who have consent from you.
We only collect the information we need to be able to provide appropriate clinical services.
We store all data securely on password-protected devices and encrypted cloud-based electronic storage. Full details are in our policies and you can request your information and/or corrections at anytime. By law we are required to store health information for at least 10 years.
We believe it is important for strong communication and collaboration with everyone on the team surrounding the child or client. With this in mind, we will need to work together to know your boundaries of who you approve to know which information. We will always check with you before we share sensitive information.
From time to time we also confidentially discuss client cases with clinical supervisors as a condition for maintaining registration with the New Zealand Speech-language Therapists Association. We do this in a non-identifying manner, however this is one reason why we ask if there is anyone who is on your non-contact list.
Do you understand and agree with our information sharing and storage policy?
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Yes
No
Other
If other, please explain:
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Who is the best person to ask permission from before we share information with others?
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Is there anyone we should not share information with? We will always check first, but it is good to know if some people or agencies are on your non-contact list.
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Any questions, concerns, or additional comments?
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Submit