Authorization to Discuss Evaluation and Treatment

Authorization to Discuss Evaluation and Treatment
Child's Name

First NameLast Name
I, Parent/Guardian First Last Name* hereby give my authorization for Creative Speech Solutions LLC, to discuss (other than Parent/Guardian):
With the following people:
Authorized Person:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child
Other
Additional Authorized Person (if applicable)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child
Other
Additional Authorized Person (if applicable)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to child
Other
If your child attends either The Uncommon Thread, SEARCH, or SOS, please check one of the options below to give us permission to share treatment plans and progress reports with the staff at these centers. This is very important so we can collaborate with them on your child's treatment and goals. Select N/A if this does not apply to you.

Other
Signature
Date

MonthDayYear
Date
Should be Empty: