PERSONAL INFORMATION
PATIENT INFORMATION
RESPONSIBLE PARTY INFORMATION
EMERGENCY CONTACT INFORMATION
INSURANCE INFORMATION
Name, Age, M/F, Speech, and Hearing or Other Medical Conditions
MEDICAL HISTORY
SCHOOL HISTORY
ASSOCIATED SERVICES
CONCERNS
HOURS OF AVAILABILITY
AUTHORIZED PERSONS
As the parent/guardian of the child listed above, I authorize discussions regarding
therapy sessions, progress, treatment plans and scheduling for my child to be held with
the following authorized persons:
CONSENT FOR SECURE RELEASE OF INFORMATION
I/WE hereby authorize and request All Together LBA PLLC to secure and/or release
medical, social, educational and other clinical information regarding the patient
named above. I/WE understand that this authorization maybe revoked in writing at
any time. Otherwise this consent automatically expires one year from the date of
signature. If not completed no information will be released from our office.
I/WE give permission for the clinician and or staff at All Together LBA PLLC to
disclose/request information information regarding scheduling of school-based
appointments, therapy, school performance, and /or any information deemed relevant
to academic therapy success. Information will not be disclosed to anyone not
specifically listed below.
I/WE give permission for All Together LBA PLLC to communicate via email,
information i.e. evaluations, therapy updates, and/or clinical information regarding the
child list above. Information will not be disclosed to anyone not specifically listed
below:
I hereby further direct that a copy of this authorization shall be deemed to be as valid
as the original for all purposes authorized herein
Please initial each item to indicate your understanding and agreement