Permission to Talk with Professionals I give Dr. Heather Summers permission to discuss my child, with the allied professionals (teachers, counselors, administrators, and other support personnel) listed below. * First Name Last Name List: (name, position, and phone number/email) * Information shared may include any of the endorsed types listed here. * Educational Psychological Psychoeducational Medical Other Please include other information below: I understand that any information disclosed with Dr. Summers will remain confidential. The act of gathering information from allied professionals is always in the spirit of support. * Yes No This consent is in effect until * Parent Signature * First Name Last Name Date * MM DD YYYY Thank you!
