This information is entirely confidential
To best serve your child and family, it may be necessary to obtain from and share information with other individuals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to work effectively with you and your child. (e.g. goals, observations, assessments, reports, etc.)
In order for us to request or receive information, please:
Fill in this form as completely as possible.
Read and sign below in both sections.
Check the boxes for each service provider you are receiving services from, and fill in any name/contact information you have about them.