Authorization for the Exchange of Information

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 (Name/Telephone #/Cell Phone #/Email)

Medication Prescriber (Name/Telephone #/Cell Phone #/Email)

Therapist/Psychologist (Name/Telephone #/Cell Phone #/Email)

School -- Teacher, School Psychologist, Principal (Position/Name/Telephone #/Cell Phone #/Email)

Another parent or guardian (Relationship/Name/Telephone #/Cell Phone #/Email)

Other (Relationship/Name/Telephone #/Cell Phone #/Email)

Other (Relationship/Name/Telephone #/Cell Phone #/Email)

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).

Leave this empty:

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Signature Certificate
Document name: Authorization for the Exchange of Information
lock iconUnique Document ID: 08aa52f4098a3098feb6d2d1524a0266ed2a082c
Timestamp Audit
September 27, 2020 9:17 am EDTAuthorization for the Exchange of Information Uploaded by Leslie Roberts - IP
October 5, 2020 12:47 pm EDT Document owner has handed over this document to 2020-10-05 12:47:47 -