Release of Information
I hereby give consent to Martin and Muir Counseling to exchange pertinent and relevant confidential information with the individual/agency identified below. I also give consent for myself or my child to be seen in Home, school or community based settings. This release will expire 1 year from the date is signed by the client/guardian/parent.
Client Name
Agency
Address
City/State/Zip
Phone
Email
Fax
Information obtained may include (check all that apply):
Type a question
Clinical Impressions and Records
Academic Records (cumulative records, report cards, standardized test scores, etc.)
Health Records
Special Education Records/504 Plan Records (IEP, 504 Plans, PPT/Student Study Team minutes, evaluations)
Psychiatric Evaluations
Psychological Evaluations
Social Work Evaluations
Educational Evaluations
Speech and Language Evaluations
Other Evaluations (vocational, occupational, etc.)
Allow Face-to-Face Meeting Time at Listed Location
Other
Client/Parent/Guardian Signature
Clear
Print Name
Relationship to Client
Date
Submit
Should be Empty: