Child's Name: *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Parent / Guardian: *

First Name

Last Name

Physician's Phone Number: *

(###)

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Physician's Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

School or Day Care Phone Number:

(###)

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School or Day Care Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If you would like for us to communicate with any other professional/person regarding your child's communication skills, e.g. physical therapist, occupational therapist, etc. please list below.

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian:

Montgomery Speech Therapy may discuss and release to the aforementioned individuals or agencies information including but not limited to: evaluation reports, treatment plans, progress notes and therapy documentation, previous medical history, as well as necessary verbal communication pertaining to the child. This information will be used for diagnostic and treatment planning purposes only. It is my understanding that this information will not be shared with any other entity without my prior knowledge. I further acknowledge that the use of this information is to ensure the best quality of care possible for my child.

First Name

Last Name

Date:

MM

DD

YYYY