Authorization for Information Exchange

To maximize the effectiveness of our evaluations, we would like to have the ability to contact other professionals working with our client. Unless sooner revoked, this consent expires six months after the last treatment or evaluation session.

I hereby authorize...

Primary Care Physician




Medication Prescriber


Therapist/ Psychologist




Check the box below if we may correspond with anyone at your child’s school or district.


Contact Name



Please include contact information for one or more of your child’s teachers and pertinent school staff, even if you have checked the box above.


Relationship to student (e.g., 2nd grade teacher)


Relationship to student (e.g., 1st grade teacher, math/reading teacher, principal, school counselor, IEP coordinator)


Relationship to student (e.g., math/reading teacher, principal, school counselor, IEP coordinator)

Another parent or guardian



Other release and/or exchange any and all pertinent information relating to to Western New England Integrated Learning Center, LLC (d/b/a Learning Solutions)


Client Name  

Parent/Guardian (if under 18)  

Leave this empty:

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Signature Certificate
Document name: Authorization for Information Exchange
lock iconUnique Document ID: af1e73e81cb47061ddba378f1d3edd3b5b704165
Timestamp Audit
October 26, 2020 2:21 pm EDTAuthorization for Information Exchange Uploaded by Leslie Roberts - IP
October 26, 2020 2:54 pm EDT Document owner has handed over this document to 2020-10-26 14:54:07 -