Child Authorization to Release Information

Child's Name

First Name Last Name

I, the undersigned, hereby authorize the party(ies) named below to speak to or release records to Dr. Tracy Bennet or obtain information or records from Dr. Bennett for myself or my child, named above.

The information checked below may include anything said in session by myself, my child, and/or ANY OTHER COLLATERAL(S) PARTICIPATING IN SESSION, including other caregivers and parents. I understand that such information may be integrated into my medical file, and that Dr. Bennett will preserve the confidentiality of such information according to the policies based on applicable portions of the California Welfare Institutions Code Section 4514.

I give permission to Dr. Tracy Bennett to release to and obtain records from (up to 6 parties):

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number

Area Code Phone Number

Records to be exchanged include (Check all that Apply)

information relevant to coordinating care my attendance in therapy my diagnosis my treatment plan when treatment was terminated and why treatment summary financial statement only all records excluding treatment notes all records including treatment notes

I understand that that this release is valid for the extent of treatment unless revoked in writing. I further understand that I may revoke this authorization at any time in writing. If you wish this release to be valid for a shorter term, please indicate the date it shall expire:

By signing below, I show that I have read and understood the terms of this release of information. I understand that Dr. Bennett does not have control over what happens to records after their release to other parties. In consideration of this consent, I hereby release Dr. Tracy Bennett from any legal liability resulting from the release of this information.

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