core4therapy_Release_of

Authorization to Release Information Form
I understand that by signing this agreement that I am giving Core4 Therapy Group permission to share
print name of child
information with
Print name of school or facility
Parent signature

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Date

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If your child will be seen for therapy at a school or daycare, please complete the section below:
Third Party Professional Services-Parent Release
I,_______________ give permission
for a therapist from Core4Thearpy Group to provide services for my child, (print child name)
Scheduling of appointments will be determined by the child care center director and the therapist from Core4 Therapy Group.

Services for my child may be provided in a group setting (classroom) or in a one-on-one setting if space is available. The representative from Core4 Therapy Group is authorized to work individually with my child in a classroom or in a private area or room; however, the representative may not remove my child from the school or daycare premises.
Parent signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization to Release Information Form