Release of Information
Date
*
-
Month
-
Day
Year
Date
For: (Client's Name)
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First Name
Last Name
Contact: (The professional you wish us to connect with)
*
First Name
Last Name
Contact Phone
*
Please enter a valid phone number.
Contact Email*
*
example@example.com
Release of information
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My/our signature(s) below grant(s) permission to North Shore Learning Clinic and the professional/contact to whom this form is addressed to freely exchange personally identifiable oral and/or written school information and Protected Health Information (“PHI”) regarding the above-named client. This information is intended for use in psychological and educational decision making. Refusal to sign will result in the information not being released. A photocopy or digital copy of this form will carry the same legal effect as the original. I have the right to revoke this consent in writing at any time, and to inspect, copy or challenge the contents of the records being requested prior to release. This release expires one year from the date above.
Client Signature
*
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Parent Signature
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