I, Name*(name of parent/caregiver), hereby grant Liberty Speech Associates LLC, their employees, and/or contractors permission to communicate with the following person or agency:Name of Therapist/Doctor/Teacher/Organization/Other: Name* Contact Information: Email and/or Phone* Information to Be Exchanged (check all that apply):Medical History SLP Evaluation(s) SLP Treatment Notes School Records (evaluations, IEP, academic reports, etc.)* I understand that:-Information may be exchanged via written and mailed report, phone call, meeting, email or fax.-This authorization will remain valid until written revocation of this authorization is presented. I can revoke this authorization at any time by writing to: Liberty Speech Associates LLC, PO Box 555, Blairstown, NJ 07825. Name of Client: Name* Date: Date* Signature of Parent/Caregiver: Signature* Relationship to Client: Relationship*