Release of Information Form

You have two options for filling out the form:

1) Scroll down and fill in the form online and submit.

2) View, download, print, handwrite your responses and bring to your first meeting with Lucia Reardon.

Download Release of Information Form

Please note that Lucia Reardon Speech Language Pathology, LLC does not accept payment through insurance companies. Clients are provided with a monthly bill that may be submitted to their health insurance, if appropriate.

Clients must read, understand and agree to the terms and conditions in the Policies and Procedures of Lucia Reardon Speech Language Pathology, LLC. Clients will be provided with a printed copy and agree to be responsible for the payment for speech and language therapy treatment, evaluation and consultation services rendered as outlined to commence and receive services.

This form will be printed out at the time of the first consultation. The parent/guardian/client will sign and date it and the form will be retained in the client’s file.

Release of Information Form

* Required information

Release of Information

Name(Required)

Name*

First Last

Client / Student Name(Required)

Client / Student Name*

First Last

release individuals

I am providing permission for Lucia Reardon, CCC-SLP, to provide speech, language, social, and executive function information for the client/student to the following professional and/or individuals:

Signature(Required)

Parent/Guardian Signature*

Date(Required)

Date*

Email

This field is for validation purposes and should be left unchanged.