Child’s Full Name *
Child's Date of Birth: *
Complete Mailing Address: *
Phone Number: *
Parent/Guardian’s Full Name: *
Email Address: *
1. The following gives authorization for Gold Speech, Inc. to share or receive records and information about:
with the following healthcare providers:*
2. Select any other providers with whom we may share information, such as a developmental pediatrician, ABA provider or BCBA, psychologist, occupational therapist, teacher or school director:
—Please choose an option—Developmental pediatricianPsychologistABA provider or BCBAOccupational therapistTeacherSchool DirectorENTGastroenterologistLCSW / MFT / Therapist / Counselor
3. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it.
4. I may revoke this authorization by notifying Gold Speech, Inc. and my therapist in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
5. This authorization expires on OR upon occurrence of the following event that relates to the client:
To be considered for services, please complete an intake form for your child or yourself.
Call: (650) 669-8539
Serving homes in Palo Alto, Los Altos, Mountain View, Sunnyvale, Santa Clara and parts of Cupertino and San Jose, California