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FORM
RELEASE OF INFORMATION
Consent
I understand that communication and collaboration between professionals can help support my child’s healing. I GIVE MY PERMISSION FOR AMY TO GIVE UPDATES AND/OR DISCUSS MY CASE WITH THESE PROFESSIONALS BELOW.
(Required)
YES
Professionals
Other professionals currently involved in my child’s health care are (ex. Doctor’s, Social worker’s, other therapist’s etc):
[1] Professionals name
Organization
Contact
[2] Professionals name
Organization
Contact
[3] Professionals name
Organization
Contact
[4] Professionals name
Organization
Contact
Guardian's information
[1] Guardian's name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Signatures of Parent/guardian(s):
Name
(Required)
Print name
Date
(Required)
Month
Day
Year
Signature
(Required)
Name
(Required)
Print name
Date
(Required)
Month
Day
Year
Signature
(Required)
Comments
This field is for validation purposes and should be left unchanged.
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