to exchange any information, medical, psychological, scholastic, or social, which may pertain to my/our child or myself. The question of privacy between the above named parties and the patient is waived. This authority extends to the furnishing of copies of all or any desired parts of the records pertaining to the above mentioned. I specifically authorize the release of information pertaining to psychological and/or psychiatric impairments, drug and/or alcohol abuse, if such is a part of my records. You are released from all legal liability that may arise from the release of the information requested.
By initialing the spaces below, you state that you understand and agree that the following health information may be disclosed.