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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 505
Corte Madera, CA 9492
littlehandsot.com

Person Completing This Form

Parent or Guardian Name: *

Relationship to Child: *

Email Address: *

Child's Name: *

School Information

Name of Child's Current School

Name of Child's Current Teacher

School Phone Number

Teacher's Email Address

Please list any other members of the child's school support team (i.e., counselor, Occupational/Speech Therapist, school psychologist, etc.) that you would like to give us permission to speak with. *

Clinician Information

This would be related to your child's diagnosis or therapies.

Clinician 1

Full Name (First, Last)

Type of Service (ABA, speech, OT, etc):

Phone Number

Email Address

Clinician 2

Full Name (First, Last)

Type of Service (ABA, speech, OT, etc):

Phone Number

Email Address

Clinician 3

Full Name (First, Last)

Type of Service (ABA, speech, OT, etc):

Phone Number

Email Address

Authorization

I authorize Little Hands to release and exchange information with all clinicians listed above.

Completion

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

clear

Questions?

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

(415) 531-3027
gp@littlehandsot.com

Little Hands
500 Tamal Plaza, Suite 505
Corte Madera, CA 9492
littlehandsot.com