SESLP - Permission to Obtain & Release Information Form

Permission to Obtain & Release Information Form: Surrey Early Speech & Language Program - SESLP
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
- Check off ALL that you are receiving service from, have received service in the past or have been referred to for service (you may be still on their waitlisted or still waiting to hear from them)
- Please sign and date the form in both the sections.
- Please note that the sections with a * are required and you will not be able to go further in the form without completing the section.
- Once the form is fully completed, click submit at the end.
Information
Name of child*

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

Street Address

Street Address Line 2

CityProvince

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 NameLast Name
Phone Number*

Area CodePhone 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 give us information on those who provide services to your family. Click on the options of service providers that apply to your family. Information fields will then appear below the list.

If you do not know a particular piece of information for a service provider, enter "N/A" or "I don't know" in that field. If the piece of information you don't know is the phone number, enter "000" for the phone number field.
Have you used, are currently using, or will use any of these services in the near future? (Select all that apply):

Family DoctorNurse PractitionerPediatricianPrivate Speech Language PathologistPreschoolDaycareElementary SchoolInfant Development ProgramSurrey Memorial HospitalSunny Hill/BC Children's Hospital (BCAAN/CDBC/TT/Cleft Palate/Other)AudiologistEar, Nose, Throat Specialist (ENT)PhysiotherapistOccupational TherapistPsychologistSupported ChildcareFoster Parent
Surrey Memorial Hospital Team (Feeding team/other Specialist):   Name*
Name of Provider:   First Name   Last Name
Address:   Address*
Phone:   Area Code* Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Sunny Hill/BCCH Team (BCAAN/CDBC/Assisted Technology/Cleft Palate/other):   Name*
Address:
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Family Doctor:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Nurse Practitioner:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Pediatrician:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Speech Language Pathologist (outside SESLP):   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Audiologist/Audiology Clinic:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of ENT Specialist:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Physiotherapist:   Name*
Name of Clinic:   Clinic name
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Occupational Therapist:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Psychologist:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Preschool:   Name*
Name of Early Childhood Educator (ECE):     First Name   Last Name
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Daycare:   Name*
Name of Daycare Provider:   First Name   Last Name
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Supported Childcare Consultant:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Infant Development Consultant:   Name*
Name of the Program: Program Name
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of Foster Parent:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Name of Elementary School/Resource Program:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Do you receive services from any other service providers not listed or not falling into the categories above?*

YesNo
Name of service provider/clinic:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Add more

YesNo
Name of service provider/clinic:   Name*
Address:   Address*
Phone:   Area Code*   Phone Number*
Email:   Email
Fax Number:   Fax Number
Name of service provider/clinic:   Name
Address:   Address
Phone:   Area Code   Phone Number
Email:   Email
Fax Number:   Fax Number
Should be Empty:

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

Information