Speech Language Pathology Assistant Consent Form Patient InformationPATIENT NAME* First Middle Last Patient Date of Birth* MM slash DD slash YYYY Legal Guardian* Email* SLP-A ConsentCheshire Center is pleased to inform you that your child’s services will be provided by a NCBOE registered Speech Language Pathology Assistant under the direction of a Certified Speech Language Pathologist in accordance with strict NCBOE licensing requirements and scope of practice guidelines.Consent* I have read and agree to the Consent for Treatment by a certified SLP-A. HiddenUntitled PhoneThis field is for validation purposes and should be left unchanged. Δ