NB Release of Information

NEWBOY
RELEASE OF INFORMATION FORM
I authorize New B.O.Y. (Breed of Youth) Mentoring & Youth Development program to contact and provide and/or obtain the below listed information for the following youth:

Information to be released by or exchanged:

History and Physical Exam

Discharge Summary

Psychiatric Evaluation

Psychological Test Results

Chemical Recovery History

Dates of Hospitalization

Court/Agency Documents

Mental Status Treatment Plans

Progress Notes

Therapist Orders

Diagnoses

Crisis Intervention Reports

Medical Records

Family Systems Evaluations
(Child's Name)
(Date of Birth)
(Parent/Guardian's Signature)

Clear
(Date)

MonthDay Year
Date
(Parent/Guardian's Printed Name)
(New B.O.Y Representative)
(Parent Email)
example@example.com
Should be Empty: