Permission to Confer with Outside Professionals Form

Permission to Confer with Outside Professionals

Client’s Name:

DOB:

I hereby give permission to the SantaRosa RiteCare® Childhood Language Center to contact other professionals working with my child. The purpose of this contact will be to share information in order to make treatment as integrated as possible. This permission will remain in effect until my child is no longer receiving services from the RiteCare® Center.

Please identify other professionals/agencies providing services to your child:

Speech Agencies (Please Specify)

Hospital (Name of Contract)

Private Speech Therapist (Name)

Social Worker/Psychologist, etc. (Name)

Regional Center (Name of Contact)

School:

Therapist:

Teacher:

Signature:

Date:[date* date-of-signature*]


"Little Learners"

Child’s Name:

Birthdate:

Age:

MaleFemale

Legal GuardiansFoster ParentsOther

Physical Address:

Mailing Address

(if different than above):

Phone:

Email:

Parents Information

Mother’s name:

Father’s name:

Married Divorced Separated MarriedDivorcedSeparated

Sibling Information List siblings/others living in the home:

Name

Age

Relationship

Referral Information

Reason for referral/Family concern

Referred by:

Are there any agencies involved? YesNo

If yes, please list:
Agency

Contact

Phone

Primary M.D.

Phone:

Other Specialist

Phone:

CLIENTS WITHOUT DOCUMENTARY PROOF OF ALL REQUIRED IMMUNIZATIONS SHALL NOT BE ADMITTED FOR TREATMENT.

Documentary proof of immunization attached Mail application to:
Santa Rosa RiteCare® Childhood Language Center
625 Acacia Lane Santa Rosa, CA 95409
Or fax to: 707.539.5905 www.childrens-speech-therapy.net