Consent to Release/Obtain Information




  • 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.
  • 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.):





  • MM slash DD slash YYYY