Harmony House LLC

Consent for Collaboration

Authorizes Harmony House to coordinate care and share relevant information with schools, physicians, therapists, and other providers.

Submitted securely to the Harmony House clinical team. Please do not use this form for emergencies — call 911, or 988 for a mental-health crisis.

What you are agreeing to

This consent is voluntary and may be revoked at any time in writing.

Information shared may no longer be protected once disclosed to third parties.

Refusal to consent will not affect your access to services.

Client name *

Date of birth *

Parent/guardian name (if applicable)

Email for your copy *

Authorize Harmony House to collaborate with *

School / educational staffPhysician / medical providerTherapist (speech, OT, PT, mental health)Social worker / case managerOther

Names, organizations, and contact details for each party *

Information that may be shared *

Assessment resultsTreatment plansProgress notesBehavioral dataAttendance recordsOther

Purpose of collaboration *

Coordination of careEducational planningMedical / therapeutic coordinationOther

Other purpose

This consent is valid until

If left blank, consent expires one year from signature or at the end of services.

I understand this consent is voluntary, may be revoked in writing, and that refusing will not affect access to services. *

Typing your full name below acts as your electronic signature.

Client / parent / guardian signatureDate

Harmony HouseABA & Home Supports

Personalized ABA and Individualized Home Supports for individuals and families across Connecticut.

This site provides general information and does not offer medical or clinical advice.