I consent for OUR HOUSE Grief Support Center to exchange information regarding my camper with my their therapist/healthcare provider. This consent allows OUR HOUSE Grief Support Center to release information regarding my child'sparticipation in group as well as interactions with agency personnel including, but not limited to my child's attendance to group sessions, behaviors and verbalizations regarding safety concerns and emotional states.
I consent for my child's therapist/healthcare provider, to exchange information with OUR HOUSE grief Support Center. This consent allows my child's Therapist/ Healthcare Provider to provide the following information: adherence to treatment including attending appointments, taking medications as prescribed, clinical risk assessments(including, but not limited to suicidality, homicidality and/or grave disability), participation in treatment planning, psychiatric hospitalizations and any other pertinent information that may impact group participation.
This consent expires one year from the date of authorization indicated by the signature at the bottom of this page