Authorization for Release of Information
Submit this form to authorize DESTINation Little Learners ABA Services to release confidential information as specified below.
DESTINation Little Learners ABA Services
415 Mountain Drive, Suite 3, Destin, FL 32541
Phone: 850-396-2658 | Email: meghan@destinationlittlelearners.com
Please use a separate form for each provider request.
I hereby give permission and consent to DESTINation Little Learners ABA Services to release confidential information (e.g., behavioral assessments/data, etc.) in the clinical record of my child/ward to the following:
Child Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Title (Mother, Father, etc.)
*
Company/School/Practice
*
Company/School/Practice
Company/School/Practice
Company/School/Practice
Parent/Guardian Name (Printed)
*
First Name
Last Name
Parent/Guardian (Signature)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Authorization
Submit Authorization
Should be Empty: