release of info -...
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CRI0913 Page 1 of 1
OFFICE USE ONLY
ID
DATE
OTHER
Heather Katchmore, M.A., CCC-SLP Pediatric Speech Language Therapist Phone: 717.256.1507 Email: [email protected] Website: www.TinyTalkersPa.com
As the parent/guardian of _____________________________________________, I hereby consent for the release of
information _____ TO and/or _____ FROM the speech-language pathologists of Tiny Talkers, LLC and its affiliates
for the coordination of services for my child. Specifically, I consent for the following persons and/or entities to consult
with Tiny Talkers, LLC, via all means of communication, regarding my child’s status in the areas of:
____ COMMUNICATION
____ BEHAVIOR
____ HEALTH/MEDICAL
____ ACADEMICS
NAME(S) OF PERSONS/ENTITIES:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
By signing below, I understand that this consent will remain effective for one year from the date of signing and that I
may withdraw this consent at any time.
CONSENT FOR RELEASE OF INFORMATION
____________________________________________________ ________________________ PARENT/GUARDIAN SIGNATURE DATE
FULL NAME OF CHILD