hereby consent to the release of information to/from (selected below) the speech-language pathologists of Happy Speech, PLLC and its affiliates for the coordination of services for my child. Specifically, I consent the following person(s)/entity(ies) to consult with Happy Speech, PLLC., via all means of communication regarding my child's status and progression with speech-language therapy.
By signing below, I understand that this consent will remain effective for one year from the date of submission/signing, and I may withdraw my consent at any time with written notice.
Today's Date: