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Child Service Release Form

Home Child Service Release Form

My Child:

will be receiving services at Handled With Care
through the following agency:

My child will be seen by a therapist for the following developmental areas:

Cognitive
Therapist Name:

Behavior
Therapist Name:

Speech
Therapist Name:

Gross / Fine Motor Skills
Therapist Name:

Dietary
Therapist Name:

I GIVE PERMISSION FOR HANDLED WITH CARE TO SHARE INFORMATION AND COMMUNICATE WITH THE AGENCY THAT PROVIDES SERVICES FOR MY CHILD. I ALSO UNDERSTAND THAT IF MY CHILD HAS AN IEP OR IFSP THAT SHARING THIS INFORMATION WITH THE FACILITY WILL HELP THE CENTER AND TEACHERS WORK TOWARDS DESIGNATED GOALS SET FOR MY CHILD THROUGH THE SERVICES RECEIVED.

Signature

DATE

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