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: