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 Number
Fax Number
Name of Individual
Name of Agency
Phone Number
Fax Number
Date
MM slash DD slash YYYY