AUTHORIZATION FOR RELEASE OF RECORDS AND COMMUNICATION

Client’s Full Name:  _____________________________

Client’s Date of Birth: ___________________

I, ___________________________, authorize and request the disclosure of the following information:

• Evaluation Reports (ABA, OT, ST, Psychology, Medical)
• Treatment Recommendations
• Client Diagnosis and Learning Profile if applicable
• IEP if applicable
• Progress Reports, Data (ABA, OT, ST, Psychology, Medical)

Information to be utilized by Gwen Fowler-Berken, MS, CCC-SLP for the following purpose(s):

• Treatment Service Coordination
• Speech – Language Review of Records and Assessment
• Assessment and Evaluation

Additional persons authorized to receive client’s medical and allied services information include the following:

_________________________________________      _________________________________________

_________________________________________      _________________________________________

_________________________________________      _________________________________________

_________________________________________      _________________________________________

I understand that I have the right to revoke this authorization at any time through electronic messaging (email) or in a formal letter.

________________________________________________

Signature of Client/Parent/POA or Legally Authorized Representative  

______________________________                                        ___________________

Relationship to Client                                                        Date