Nominee Consent Autism Assessment

I am filling this out

on behalf of a child in my care
as an adult for my own assessment

Parent/Guardian Name

First

Last

Client Name

First

Last

Email

I understand that completing a comprehensive autism assessment requires input from others that know my child well

Yes
No

e.g. teacher, educator, family member, or family friend.

I give consent for Speechcare to contact my nominated person to request and receive relevant information

Yes
No

e.g. MIGDAS-2 Teacher Questionnaire

I understand that completing a comprehensive autism assessment requires input from an important person nominated by me

Yes
No

e.g. teacher, educator, family member, or family friend

clinician nominated Date

I give consent for Speechcare to contact my nominated person to request and receive relevant information.

Yes
No

Contact Details for Nominated Person:

Nominee's Name

First

Last

Nominee's Email

Nominee's Number

Nominee's Name

First

Last

Nominee's Email

Nominee's Number

Observation & Training Consent:

Sometimes a second clinician or student speech pathologist may observe sessions for training purposes. Let us know if you are happy for this to happen. This is your choice and will not affect your sessions being booked or access to services.

I consent to a second clinician or student speech pathologist being present during sessions

Yes I'm happy for a second clinician or student being present during sessions
No I do not want a second clinician or student being present during sessions

Signature

Clear Signature

Full Name

First

Last

Today's Date

AUTISM ASSESSMENT NOMINEE CONSENT FORM

Contact Details for Nominated Person:

Observation & Training Consent: