CONSENT FOR RELEASE OF INFORMATION

As the parent/guardian of: *

Enter Child's Full Name

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.

Direction of Communication *

TO
FROM

Select "TO" if information should be provided from HAPPY SPEECH, PLLC to the person/entity. Select "FROM" if the person/entity below will be providing information to HAPPY SPEECH, PLLC. Select "TO" and "FROM" if information should be provided bi-directionally to the person/entity provided below.

Enter the name of the person/entity below (one per line): *

Please provide name and contact information for each person/entity information should be shared with.

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.

Name of parent/guardian *

First

Last

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Expiration Date

Select a date you'd like this consent to expire. Expiration dates GREATER than 1-YEAR from TODAY'S DATE will expire 1 YEAR from TODAY. You may leave this field blank to consent to expire 1-year from TODAY.

Today's Date:

Signature *

Please provide your email address so we may send you a copy of this document: *

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