SESLP - Permission to Obtain & Release Information Form

Permission to Obtain & Release Information Form: Surrey Early Speech & Language Program
This information is entirely confidential

To best serve your child and family, it may be necessary to obtain from and share information with other individuals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to work effectively with you and your child. (e.g. goals, observations, assessments, reports, etc.)

In order for us to request or receive information, please:
- Fill in this form as completely as possible
- Read and sign below in both sections.
- Initial each/all services you are receiving/have received (must provide at least the names of the agencies/providers you've received services from).
Information
Name of child *

First Name Last Name
Child's Date of Birth *
Home Address

Street Address

Street Address Line 2

City Province

Postal / Zip Code
By signing below, I hereby give permission to obtain and release verbal or written information from the following individuals and agencies to Surrey Early Speech and Language Program:
Name of Legal Guardian *

First Name Last Name
Phone Number *

Area Code Phone Number
Today's Date *
Signature *
In order to quickly provide information and reports to you or other professionals providing service to your child, we sometimes use email or fax. We take precautions using email and fax in an attempt to protect your privacy. However, you need to be aware that faxing or emailing information does include the risk of personal information being accidentally disclosed to other people (e.g. on the web). For this reason we need your permission to send reports through email or fax.
Do you authorize us to send reports and information on your child through email or fax? *

Yes, I give my permission to send reports on my child through email or fax. No, I do not give permission to send reports on my child through email or fax. All reports must be sent through the mail.
Signature *
Today's Date *
This authorization will expire 12 months from the date of this signature,
or sooner at family’s request.

Please share any information you have on the individuals/agencies that work with/provide services to your child:

Do you use this service?

Name/Agency

Address Information

Phone Number

Community Audiologist

Surrey Memorial Hospital

Sunny Hill/BC Children’s Hospital (BCAAN/CDBC/TT/Cleft Palate)

Family Doctor

Pediatrician

Speech Language Pathologist

ENT

Physiotherapist

Occupational Therapist

Psychologist

Preschool/Daycare

Supported Childcare

Infant Development

Foster Parent

School

Do you receive services from any other service providers not listed or not falling into the categories above?

Yes No
Please enter the information for these other service providers below:
Should be Empty:

Permission to Obtain & Release Information Form: Surrey Early Speech & Language Program

Information