FamilyPath  Autism  Services,  LLC  |  575  D’Onofrio  Dr  Suite  101  |  Madison,  WI    53719  |  608.512.0780  |  familypathautism.com  

Consent  to  Release  of  Information  

Client  Name Date  of  Birth

Address

City State Zip  Code

Authorizes  FamilyPath  Autism  Services,  LLC    to  (check  appropriate  boxes)      Release  information  to:      Obtain  information  from:      Exchange  information  with:      Phone  contact  on  with:  

Name of Agency/Organization

Address

City State Zip  Code

Purpose  or  need  for  disclosure  (check  all  that  apply)      Evaluation  /  Assessment        Treatment  Coordination  

   Further  psychological  care      To  process  insurance  claim      Other  (specify):    

Specific  information  to  be  disclosed  (check  all  that  apply)  

   Complete  record        Therapy  Notes  /  Treatment  Summary      Initial  Assessment  /  Evaluation        Diagnostic  Evaluation  /  Assessment  

   Medical  diagnosis  /  Treatment  records      Psychological  testing  /  evaluation        School  records      Recommendations        Progress  reports        Discharge  Summary  

   Other  (specify):    

This  consent  will  remain  in  effect  for  one  (1)  year  from  the  date  of  signing  unless  revoked  in  writing  by  me  at  an  earlier  date.      I  have  read  ,  understood  and  accepted  the  additional  information  affecting  release  of  records  

printed  on  the  back  of  this  form.    I  have  had  full  opportunity  to  read  and  consider  the  contents  of  this  Authorization,  and  I  confirm  that  the  contents  are  consistent  with  my  direction  to  the  health  care  provider.  I  understand  that,  by  signing  this  form,  I  am  confirming  my  authorization  that  the  health  care  provider  may  use  

and/or  disclose  to  the  persons  and/or  organizations  named  in  this  form  the  protected  health  information  described  in  this  form.  

Printed  Name  of  Parent/Guardian

Signature  of  Parent/Guardian Date