PMT Consent To Exchange Information

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The purpose of this form is to obtain your consent since a printer and signed copy is not available at your location. Approved information includes written documents and verbal discussions. This consent also applies to the exchange of information with the below indicated individuals and organizations through e-mail.

Email *

Client's First & Last Name *

Who is completing this form? Either CLIENT-SELF or Guardian/POA (FULL NAME and RELATIONSHIP of Guardian is required) *

I authorize Piedmont Music Therapy, LLC to release necessary and pertinent information on behalf of client to the following parties: *

Case Manager

Occupational Therapist

Physical Therapist

Physician

Speech Therapists

Teacher

Other:

Required

Please list NAME, PHONE NUMBER & EMAIL ADDRESS for approved individuals whom PMT may discuss client's treament with: *

Please date this consent: *

YYYY

Please list the time of this consent: *

Time

Thank you for providing consent for exchanging information in order for the Board Certified Music Therapists on Staff at Piedmont Music Therapy, LLC to work more effectively. We are proud to offer services for individuals of all abilities in Greater Charlotte of the Carolinas. #safetyiskey

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Piedmont Music Therapy. Report Abuse

Forms