AUTHORIZATION TO RELEASE INFORMATION

I,  , hereby authorize the release of information about my child,   , from:

to: Laura D. Fleming, M.S.
Gateway School
2570 NW Green Oaks Blvd
Arlington, TX 76012

I specifically authorize the release of information concerning:

Psychological assessment and results

Psychological treatment

Medical treatment

Other:

Signature of Child: ____________________________________________Date: _____________
(If over 18 years old)

Signature of Parent/Guardian ___________________________________Date: ______________

I,   , also authorize the release of information about my child,  , from:

Laura D. Fleming, M.S.
Gateway School
2570 NW Green Oaks Blvd
Arlington, TX 76012

to:

I specifically authorize the release of information concerning:

Psychological assessment and results

Psychological treatment

Medical treatment

Other:

for the purpose of improving my child’s quality of care and facilitating treatment.

Signature of Child: ____________________________________________Date: _____________
(if over 18 years old)

Signature of Parent/Guardian ___________________________________Date: ______________

This consent expires on ____________________, 6 months from date of signature.