Authorization for Information Exchange


If the client is under 18, please check the box for school and list the names and emails of their primary teachers. We require teachers to complete a survey as part of the evaluation process.

(If client is 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.

I hereby authorize...

Primary Care Physician

 

Telephone/Cell/Email

 

Medication Prescriber

Telephone/Cell/Email

Therapist/ Psychologist

Telephone/Cell/Email

 

School

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

  

Contact Name

Telephone/Cell/Email

 

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.

Teacher

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

Teacher/Staff

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

Teacher/Staff

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

Another parent or guardian

 

Other

Other

 

...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)

 

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: 4ba3904f24eee07afd79dc37eebd30fd98ae416e
Timestamp Audit
October 26, 2020 2:21 pm ESTAuthorization for Information Exchange Uploaded by Learning Solutions - ls@learningsolutionsls.com IP 173.166.26.162
October 26, 2020 2:54 pm EST Document owner joanne@joannepinatel.com has handed over this document to learningsolutions@learningsolutionsls.com 2020-10-26 14:54:07 - 96.39.16.94
February 3, 2023 2:10 pm EST Document owner learningsolutions@learningsolutionsls.com has handed over this document to ls@learningsolutionsls.com 2023-02-03 14:10:54 - 173.166.26.162