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*