AUTHORIZATION FOR RELEASE OF INFORMATION
Client Name: ___________________________________________________
Date of Birth: __________________
Name of Person, Organization, Institution:
Address, Phone Number, E-mail of
Contact:
I give permission for the following information to be shared and exchanged with Kids
Express Speech Therapy.
___Medical Records
___Education/Academic Records
___Teachers Report
___Behavior Report
___Psychological/Psychiatric Records
___Verbal Exchange
___Electronic Communication (e-mails, etc.)
X___________________________________________ Date_________________
Signature of parent/guardian