Authorization for Release of Information

Authorization for Release of Information

Please complete for the client's SCHOOL
Client Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Date
I, hereby, as the parent or guardian of a child under the age of 18 years of age, or , I, as an eligible adult (18 years of age or older), do request and authorize: Behaven Kids to receive and provide the information below: *

Official permanent record (parent's name, child's name, birth date, progress notes, data, standardized test scores, attendance data) Results of psychological assessments and/or consultations Medical records Other Data
If other data was marked, please explain:
Institution or person receiving/providing information; please list the name of the school: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Purpose for which the information is to be released: *
This authorization shall be deemed to permit the continuing release of the designated information from the date signed through the following date, or until such time that this authorization shall have been revoked by me in writing: *

Month Day Year
Date
I refuse to release information to providers for coordination of care (please initial if applicable) *
Name of Guardian: *

First Name Last Name
Date *

Month Day Year
Date
Electronic Signature *
Phone Number *

Area Code Phone Number
Should be Empty: