We are committed to protecting your privacy and handling your information in a secure, confidential manner. Information you provide may include personal and health‑related details that are considered Protected Health Information (PHI) under applicable privacy laws.
By submitting this form:
- I consent to A‑SPAN collecting, using, and securely storing my information for the purpose of coordinating a free one‑hour consultation, including matching me with an appropriate professional.
- I understand that my information will be kept confidential and shared only with authorized personnel or professionals as necessary for consultation and service coordination.
- I understand that reasonable safeguards are in place to protect my information, but that electronic communication may carry inherent security risks.
- I understand that I may request access to, correction of, or restrictions on my information, and may withdraw my consent at any time in writing, as permitted by law.
Service Clarification
- I understand that completing this form does not guarantee an evaluation, diagnosis, or ongoing treatment.
- I understand that the free consultation is informational only and does not replace a formal clinical assessment or medical advice.
- I understand that services are subject to provider availability and scope.
- I acknowledge that my information will be used only for coordinating speech‑language and audiology consultation services and will not be used for marketing or shared without my permission, except as required for care coordination or by law.
Agreement