Pediatricadvanced_Consent_to_Release

CONSENT FOR THE RELEASE & EXCHANGE OF INFORMATION
I give permission for the exchange of information (verbal and/or written) regarding my child, Child's first name*to be shared between Pediatric Advanced Therapy and Name/Position
Agency/School
Address
Phone
Please enter a valid phone number.
I understand that unless otherwise indicated, this information will be used only for treatment oreducational purposes such as assessments, curriculum programming and coordination of services.I also understand that the agency receiving this information will be responsible for the confidentiality of this information.
Parent*
Date

MonthDayYear
Date
Should be Empty:

CONSENT FOR THE RELEASE & EXCHANGE OF INFORMATION