Release of Information

Solutions Parenting Support
Parent Coaching and Transitional Services

AUTHORIZATION TO RELEASE INFORMATION TO SOLUTIONS PARENTING SUPPORT

Authorization*
I hereby authorize the release and disclosure of any information that can be provided regarding the therapeutic work that is being or has been provided in relationship to parenting support and our family system.
First Last
Please release both written and verbal information to:*
- Solutions Parenting Support
  5462 N. Flint Ave.
  Tucson, AZ 85704
  Office 970-871-1231
  Email admissions@solutionsparentingsupport.com
Please release both written and verbal information from:*
First Name of Professional Last Name of Professional
Professional's Email Address:*
Professional's Phone Number
Professional's Company Address
Company Name Address City State / Province / Region ZIP / Postal Code Country
Please release both written and verbal information from:
First Name of Professional Last Name of Professional
Professional's Email Address:
Professional's Phone Number
Professional's Company Address
Company Name Address City State / Province / Region ZIP / Postal Code Country
Please send the following Information release as indicated below:
- Family Admit/Treatment History
- Family System Therapeutic Progress
- Family Discharge Recommendations
- Purpose: The family’s identifiable clinical information received pursuant to this release authorization is to be used for the following purposes: Treatment overview and recommendations for the family system and will not be released to anyone but Solutions Parenting Support.
Purpose: The client’s identifiable health information received pursuant to this release authorization is to be used for the following purposes: Treatment overview and recommendations of said client, their family system and will not be released to anyone but Solutions Parenting Support.
Release of Information Authorization
- I understand the clinical information and records requested for release are protected by Federal Regulation and cannot be disclosed without my written permission unless otherwise provided for in such regulations. I also understand my consent for disclosure is subject to my written revocation.
Name of Client*
First Last
Client's Date of Birth*
Month
Day
Year
Name of Parent/Guardian*
First Last
Parent/Guardian Email*
Signature of Parent*
Today's Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Release of Information

Solutions Parenting Support Parent Coaching and Transitional Services

Solutions Parenting Support
Parent Coaching and Transitional Services