I hereby authorize the exchange of medical, psychosocial, educational, and developmental information regarding Child's Name . Date of Birth
Contact #1: Name: First Name Last Name Relationship: Physician, teacher, etc. Email: Email Phone Number: Area Code Phone Number Please check all that apply to Contact #1:Scheduling Clinical Reports Billing Sensory Processing Measure (SPM-2) School Questionnaire All of the above Other Please provide detail for "Other" option
Contact #2: Name: First Name Last Name Relationship: Physician, teacher, etc. Email: Email Phone Number: Area Code Phone Number Please check all that apply to Contact #2:Scheduling Clinical Reports Billing Sensory Processing Measure (SPM-2) School Questionnaire All of the above Other Please provide detail for "Other" option
Contact #3: Name: First Name Last Name Relationship: Physician, teacher, etc. Email: Email Phone Number: Area Code Phone Number Please check all that apply to Contact #3:Scheduling Clinical Reports Billing Sensory Processing Measure (SPM-2) School Questionnaire All of the above Other Please provide detail for "Other" option
Contact #4: Name: First Name Last Name Relationship: Physician, teacher, etc. Email: Email Phone Number: Area Code Phone Number Please check all that apply to Contact #4:Scheduling Clinical Reports Billing Sensory Processing Measure (SPM-2) School Questionnaire All of the above Other Please provide detail for "Other" option
Contact #5: Name: First Name Last Name Relationship: Physician, teacher, etc. Email: Email Phone Number: Area Code Phone Number Please check all that apply to Contact #5:Scheduling Clinical Reports Billing Sensory Processing Measure (SPM-2) School Questionnaire All of the above Other Please provide detail for "Other" option
This consent is valid and in effect for two years, unless written request to renew or withdraw this form is provided.
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