Records Release & Conferral Authorization

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Information Release Authorized to (full name):

Email:

Address:

Phone Number (numbers only):

Fax Number (numbers only):

I authorize and request you to release all relevant information and records related to communication, feeding, behavior, and/or methodologies used.

Child/Client:

Child/Client Date of Birth (MMDDYYYY):

Child/Client Address:

Phone Number (numbers only):

Date (MMDDYYYY):

Digital Signature (Parent or Legal Guardian):

Relationship to Child/Client: