CONSENT TO RELEASE OR EXCHANGE INFORMATION SCHOOL-BASED MENTAL HEALTH SERVICES

authorizes Vanda Counseling and Psychological Services, PLCC, 14115 James Road #305, Rogers, MN 55374 to give information to and receive information from St. Michael-Albertville School District 885, St. Michael/Albertville, MN (“STMA Schools”). This release authorizes Vanda Counseling and STMA Schools to release and/or exchange pertinent information from my case record by electronic, paper, or verbal communication.

I specifically authorize Vanda Counseling to contact me and work directly with STMA Schools to set-up and coordinate the start of school-based mental health services. I also understand that, once services have started, my signature on this form authorizes the disclosure of pertinent mental health information and school records. Further, I authorize STMA Schools to release/disclose records to Vanda Counseling and Psychological Services, PLLC that they may have received from third parties that STMA Schools considers pertinent to my mental health services. Finally, I understand that the purpose of this disclosure is to provide school-based mental health services at STMA Schools and coordinate care with pertinent school staff. I understand that a photocopy/fax of this release is equivalent to the original.

I understand that I have the legal right to refuse to sign this consent. If I refuse to sign this consent, treatment will not be able to be held at STMA Schools due to an inability to provide confidential services in the school setting. Should you request not to sign this form, you will be provided with three referral options where mental health services may be held outside of the school setting. I understand that I may revoke this consent at any time with written notification, but that the revocation will not have any effect on the information released prior to notification of cancellation. I understand that this consent expires one year after signature date.

I realize that Vanda Counseling and Psychological Services, PLLC cannot prevent the redisclosure of records released as a result of this request; therefore Vanda Counseling is released from any and all liability resulting from disclosure. I do not authorize re-release of this information to anyone. If a responsible party for minor party is authorizing this form, the responsible party understands he/she must have legal authority to act on the minor party’s behalf.

IF YOU ARE THE CLIENT’S LEGAL REPRESENTATIVE, PLEASE ATTACH A COPY OF THE DOCUMENT THAT GIVES YOU AUTHORITY TO ACT AS THE LEGAL REPRESENTATIVE.