I, the undersigned, hereby authorize the party(ies) named below to exchange information with Dr. Tracy Bennett about myself AND my child(ren), named above.
Specific information that I authorize for release and receipt is detailed below. Checked items may include records and/or anything said in session by myself or my child. Information that may have been integrated into the medical file may also include content shared via email, posted mail, or text.
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.