Consent

to Treat/Release Information
Date:
I, (Legal Guardian)_____________________________authorize Wellspring Therapy Services to
evaluate and/or treat (client) _________________________ and/or provide Speech and
Language Therapy.
I, (Name)______________________________ authorize Wellspring Therapy Services to release
and obtain clinical information regarding said client to and from the following persons or
agencies.
Name 1: ______________________________________________________________________
Address 1: _____________________________________________________________________

Name 2: ______________________________________________________________________
Address 2: _____________________________________________________________________

In consideration of treatment and educational purposes, I give consent that sound recordings,
records, and/or photographs may be used as deemed helpful by the staff. I understand that
the information may be discussed with other Speech Pathologists within the office and/or
clients Physician regarding evaluation and/or treatment goal strategies.
This form has been fully explained to me/us, and I/we understand the contents.
Signature: __________________________________________Date: _____________________

1123 MD Route 3, Suite 252, Gambrills, MD 21054 240-620-3028