Authorization for Information Exchange
(If child under 18)
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.
Primary Care Physician
Check the box below if we may correspond with anyone at your child’s school or district.
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
...to release and/or exchange any and all pertinent information relating to to Western New England Integrated Learning Center, LLC (d/b/a Learning Solutions)
Parent/Guardian (if under 18)
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Information Exchange
Agree & Sign