This release does NOT give permission to utilize social media and/or platforms other than texting or email exchange.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain support and services from StarBright Applied Behavior Analyst
I understand that I may withdraw my authorization at any time. I understand also that such withdrawal of my authorization may not be effective to prevent disclosure of information previously authorized or to stop previous action that has been taken in reliance on this authorization.
My signature means that I have read this form and/or have had it read to me and explained in language I can understand. I know what information will be disclosed, and in what manner, and give my voluntary consent to its release.
My signature means that, if I am not signing for myself, I have the legal authority to sign for the identified individual. My signature confirms that I am the legal representative/guardian for the identified individual.