Client Contract

Thank you for selecting WNY Speech Therapy as your provider for speech therapy services. This contract identifies the expectations and duties of the speech-language pathologist, client, and/or client’s parties for speech services to be provided.

WNY Speech Therapy and ________________________ hereby agree to the terms set forth below:

Notification of Legal and Privacy Policies

  • Speech Therapy services are provided at WNY Speech Therapy by Miriah Brunetto, M.S., CCC-SLP, a New York licensed and ASHA-certified speech-language pathologist.
  • WNY Speech Therapy will not be held responsible for any claims or damages of any kind, for injury to any person or persons, and/or for any damages due to loss of property arising directly or indirectly out of participation in these therapy sessions
  • All client information will be kept confidential. It will be kept in a secure location away from public access.
  • Evaluation reports, progress reports, therapy goals and therapy plans will be sent to outside sources (i.e- doctor’s offices, insurance providers) in a private manner, if applicable.
  • Written approval will be obtained to share private information with other outside sources or professionals.
  • This is the entire agreement and no promises outside of the agreement made on or before the effective date will be binding upon the parties

Cancellations

  • All client cancellations require at least a 24-hour notice, failure to do so will result in a no-show fee of $75.
  • If we are unable to keep a therapy appointment for any reason, we will notify you as soon as possible, and a make-up appointment will be scheduled.

Sessions

  • Speech Therapy services will be provided based on goals agreed upon by both parties in order to best serve our client. Goals can be established through one or more of the following means: Administered evaluations/reports, outside evaluations/reports, observations, and client/parent requests
  • Evaluations will range from 60 to 90 minutes in length. Treatment sessions will range from 30 minutes to 60 minutes in length. Each session will be tailored towards what would best serve your individual needs.

Financial Policy

  • Payment is expected at the time of service
  • If payment is not received, a reminder will be sent out. If payment is not made for three sessions, therapy will be discontinued until the account is paid in full
  • Forms of payment accepted are cash, credit cards (subject to a 3.99% fee), or check (made payable to: Miriah Brunetto). A $25 fee will be applied to all bounced checks.
  • The rates of evaluations and therapy are subject to change.

I read, understand, and agree to the policies outlined above. This is the agreement in its entirety, and no promises outside of the agreement made on or before the effective date will be binding upon the parties. My signature indicates that I consent to all rules and regulations of WNY Speech Therapy.


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