Request/Authorization for Release of Information

Name of Child: ________________________________ Name of Parent:______________________________________

Address: _______________________________________________________________________________________

Phone: ____________________________ Childs’s Birth date: ______________________________________________

I give my permission to (select only one):

�   the professional named in the letterhead at the top of this form, or

�   _____________________________________________________________________________________

of   _____________________________________________________________________________________

________________________________________________________________________________________

to release specified information concerning my minor child, in order to:

�  Assist with treatment planning

�  Document a need for services

�  Support an application for  ________________________________________________________________________

�  Other: _______________________________________________________________________________________

_______________________________________________________________________________________________

and to communicate that information to (select only one)

�   the professional named in the letterhead, or to

�   ____________________________________________________________________________________________

of   ___________________________________________________________________________________________

The information shall include: _______________________________________________________________________

______________________________________________________________________________________________

I understand that I may revoke this consent at any time except to the extent that action based on this consent has already been taken.  This informed consent for the release of information will automatically expire without further action ninety days after the date on which it was signed.

I hereby release Kate Mack, Ph.D. from all legal responsibility that may arise from the release of the above requested information. This authorization is fully understood and it is made voluntarily and with informed consent on my part.

___________________________________    _____________________________________   ____________________

Signature of client                                                            Printed name                                                     Date

___________________________________    ______________________________________   ___________________

Signature of parent/guardian                                           Printed name/ Relationship                             Date

I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature.

_____________________________________    ___________________________________   ____________

Signature of witness                                 Printed name                                            Date

� Copy for client or parent/guardian  � Copy for source of records  � Copy for recipient of records