Authorization for Release of Information

Name of Client: Student’s name.

Date of Birth: Student’s DOB

I request and authorize:	Tonya Klem, Ed. S.

To obtain from or exchange with: Name of Person or Agency

Address.

the following information:

Academic Records	Teacher Interview

Psychological Testing	Medical History

Other: Other info to be obtained.

for the purpose(s) of: Reason information needs to be released.

All information I hereby authorize to be obtained from this person or agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that I have the right to inspect and receive a copy of the material to be disclosed. I understand that this authorization will remain in effect for 90 days unless I specify an earlier expiration date here: Earlier Date. I may revoke this authorization at any time except to the extent that information already released pursuant to this consent cannot be recalled.

_____________________________________	__________________

Signature of Client or Guardian	Date

IF PATIENT WITHDRAWS CONSENT

_____________________________________	__________________

Signature of Client (withdrawn consent before 90 days)	Date