Consent to Release Information Date* Child's Name* D.O.B.* Age*Parent's Names* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mobile Phone*Home Phone*Name of Contact(s) and contact information (phone/email):*Signature* Reset signature Signature locked. Reset to sign again I hereby give permission to representatives of Connect Plus Therapy to contact the above listed individuals in regard to my child of this form. Representatives of Connect Plus and these individuals may both share confidential information with each other including written reports, verbal consultation, and email consultation.
