I _______________________ ________ give permission for Blessed ABA Therapy Service. to contact you for Coordination of Care and medical and treatment records marked below for the patient listed above. Thank you, your text

Currently receiving treatment for

Treating Provider(s) Information

Medication(s) and Dosages

Significant information that may impact medical or behavioral health, including hospitalizations, and any descriptions of chronic medical illness:

* If you would like to discuss this client/patient’s treatment, please contact me at the number above.