PMT Consent To Exchange Information
The purpose of this form is to obtain your consent since a printer and signed copy is not available at your location. Approved information includes written documents and verbal discussions. This consent also applies to the exchange of information with the below indicated individuals and organizations through e-mail.
Email address *
Client's First & Last Name *
Your answer
Who is completing this form? Either CLIENT-SELF or Guardian/POA (FULL NAME and RELATIONSHIP of Guardian is required) *
Your answer
I authorize Piedmont Music Therapy, LLC to release necessary and pertinent information on behalf of client to the following parties: *
Required
Please list NAME, PHONE NUMBER & EMAIL ADDRESS for approved individuals whom PMT may discuss client's treament with: *
Your answer
Please date this consent: *
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YYYY
Please list the time of this consent: *
Time
:
Thank you for providing consent for exchanging information in order for the Board Certified Music Therapists on Staff at Piedmont Music Therapy, LLC to work more effectively. We are proud to offer services for individuals of all abilities in Greater Charlotte of the Carolinas. #safetyiskey
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