Release of Information

Timber Ridge Pediatric Therapy, LLC

Release of Information
The below agreement is effective beginning the date below and will remai in place indefinately or until a new release is submitted.

Timber Ridge Pediatric Therapy, LLC will send a copy of all evaluations and progress notes to your pediatrician, and the referring professional. If you do NOT want the reports automatically sent, please contact us.
Name of client *

First Name Last Name
Client date of birth *

Month Day Year
Date
I give Timber Ridge Pediatric Therapy, LLC permission to share information (written reports, phone conversations, meetings, e-mail correspondence) with the following people (pediatrician, school, other therapists, etc.): *
Signature

Clear
Name of person filling out this form *

First Name Last Name
Relationship to client
Today's date *

Month Day Year
Date
Should be Empty:

Timber Ridge Pediatric Therapy, LLC