I hereby authorize the release of the medical records of my minor child (named below) by Aimee E. Short, LPC, to the individuals listed below for the purpose of: 

I acknowledge that this consent form permits Aimee E. Short, LPC, to access, review, and disclose my minor child's medical records as required for the stated purpose.

I am aware that this release will remain valid and in effect until either I formally revoke this permission in writing, or the minor reaches the age of consent according to the laws of the state of Arizona.

I understand that the information disclosed may include, but is not limited to, medical and psychological evaluations, treatment plans, progress notes, test results, and any other relevant medical or mental health

I acknowledge that my child's privacy rights will be respected and that the disclosed information will be handled in accordance with applicable laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and other relevant state and federal laws.

I hereby release Aimee E. Short, LPC, and any individuals or entities involved in the release, transfer, or disclosure of my child's medical records from any liability that may arise from the release of said records for the specified

I understand that I have the right to request a copy of this signed consent form for my records.