Client Name *

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Client Date of Birth *

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I authorize Pencil & Pathways to *

Release Information To

Obtain Information From

*

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Purpose of Disclosure (check all that apply) *

Coordination of Care

Educational Planning

Psychological Evaluation

Speech & Language Evaluation

Legal Purposes

Other

Information to Be Released (check all that apply)

Psychological evaluation reports

Counseling/treatment notes

Academic records

Behavioral data/observations

Functional Behavior Assessment (FBA) and/or Behavior Intervention Plan (BIP)

Attendance records

Other

Method of Disclosure (check all that apply): *

Written report

Verbal communication

Electronic transmission (secure email, encrypted file sharing)

The authorization will expire on: *

(Cannot exceed one year from signature date.)

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Your Rights: You may revoke this authorization at any time in writing, except to the extent that action has already been taken. Information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected under HIPAA. Signing this form is voluntary. Services will not be conditioned on signing this authorization unless the services are solely for the purpose of creating protected health information for a third party. *

If you are in agreement, please write your name below.

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