Consent to Release/Obtain Information Parent/Guardian First Name:* Parent/Guardian Last Name:* Relationship to Child:* Phone Number:*Email Address:* I, the parent/guardian, do hereby authorize EBS Children’s Institute of Oxford to RELEASE TO and OBTAIN INFORMATION AND DOCUMENTATION FROM the record of the individual identified below for therapeutic purposes including collaboration, planning, and treatment.Child's Name* Date of Birth* MM slash DD slash YYYY I authorize information and documentation to be shared with or obtained from the following (i.e. pediatrician, school staff, outside therapists, etc.): Name of Individual Name of Agency Phone NumberFax Number Name of Individual Name of Agency Phone NumberFax Number Date MM slash DD slash YYYY