Intake Form:  Release of Information (Little Hands)
 
Little Hands - Intake Form (Occupational Therapy)

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Release of Information

Please complete the following to give Little Hands Occupational Therapy the right to release and exchange information regarding your child’s Occupational Therapy and/or Speech Therapy. 

Questions?

Gabrielle Perelmuter, MOT OTR/L
Clinical Director & Occupational Therapist

(415) 531-3027
gp@littlehandsot.com

Little Hands
500 Tamal Plaza, Suite 527
Corte Madera, CA 9492
littlehandsot.com

Person Completing This Form

School Information

Clinician Information

This would be related to your child's diagnosis or therapies.
Clinician 1
Clinician 2
Clinician 3
Authorization

Completion

I certify that the information I have provided above is accurate to the best of my knowledge. *
clear
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Questions?

Gabrielle Perelmuter, MOT OTR/L
Clinical Director & Occupational Therapist

(415) 531-3027
gp@littlehandsot.com

Little Hands
500 Tamal Plaza, Suite 527
Corte Madera, CA 9492
littlehandsot.com