Consent to Communicate

Consent to Communicate

Authorize communication with relevant professionals involved in your child's care.
Parent / Guardian Full Name
Child’s Full Name
I authorize communication with:
Other Professional
Name(s) of Specific Provider(s) or Organization(s)
I give permission to Pediatric Therapy Bridge LLC and its therapists to communicate with the professionals listed above for the purpose of coordinating services and supporting my child’s care. This communication may include evaluation results, treatment goals, progress updates, recommendations, attendance, and other relevant information necessary for coordination of care. I understand this authorization is voluntary and may be revoked at any time in writing.
This consent remains valid until services cancelled or until cancelled by parent/guardian in writing to office@pediatrictherapybridge.com
Parent / Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Child
Should be Empty: