Child - Authorization and Consent for Release and Disclosure of Confidential Information

1

Parent or guardian information* This field is required.

Full Name

Date of birth

Full address including zip code

Phone number

2

Minor's information* This field is required.

Full Name

Date of birth

4

If you have not yet been assigned a therapist, please call our intake department at 646-389-5801 or fill out the Contact Form on our contact page. Please do not fill out the rest of this form.

5

I authorize and give my consent to the above-named practitioner and/or the administrative and clinical staff of the above named practitioner to discuss all aspects of my child's medical, psychotherapy and/or psychiatric treatment without restriction or qualification with: * This field is required.

Name of collateral individual

Organization collateral individual is affiliated with

Phone number of collateral individual

Fax number of collateral individual

6

Today's date* This field is required.

Date

7

Signature* This field is required.

Clear