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Child's Information
First Name*
Last Name*
Child's Date Of Birth*
Month
Day
Year
Parent's Information
First Name*
Last Name*
Address Information
Address*
Street Address Address Line 2 City State ZIP Code
I authorize*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number of authorized*
Fax Number of authorized*
Email address of authorized*
Please select one of the following:*
- Release the following information to Next Gen Therapy LLC
- The above agency and Next Gen Therapy LLC to exchange information with each other on an ongoing basis for the duration of the terms of this release. This release needs to be renewed annually unless terminated at an earlier time by written notification.
Any information released or exchanged may not be disclosed to any other agency except those required by law. The following information is included in this release:
Please check all that apply:*
- Psychiatric Evaluation
- Social History
- Discharge Summary
- Individualized Education Plan
- Diagnostic Information
- Psychological Evaluation
- Treatment Plan & Reviews
- Test Results: Physical Exam/Audiology/Visual
- Other
This consent automatically expires 30 days after termination of services.
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Child's Information