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
Statement for Verbal Consent Authorization: We kindly request your verbal authorization to sign the consent on your behalf. By providing your verbal consent, you acknowledge and agree that Martin and Muir may act as your authorized representative for the purpose of signing the consent document. Your verbal consent will be duly noted and documented by our team. Please proceed by affirming your consent verbally. Client/Parent/Guardian Signature
Print Name
Relationship to Client
Date
Submit
Should be Empty: