Feeding Client Consent to Release/Obtain Information



  • I, the parent/guardian, do hereby authorize EBS Children’s Therapy to RELEASE TO and OBTAIN INFORMATION AND DOCUMENTATION FROM the record of the individual identified below for therapeutic purposes including collaboration, planning and treatment.
  • MM slash DD slash YYYY


  • I authorize information and documentation to be shared with (i.e. pediatrician, school staff, outside therapists, etc.):



  • MM slash DD slash YYYY