release of information

North Texas Family Services

Lauren Gordon, LCSW

8301 Lakeview Parkway Suite 111-131

Rowlett, TX 75088

214.675.3978

Directions: Please include yourself and any minor children you have legal responsibility for (conservatorship, guardianship, "custody," etc). Please use additional copies if needed.

Client(s):
Your name:

First NameLast Name
DOB
Child #1 Name

First NameLast Name
DOB
Child #2 Name

First NameLast Name
DOB
Child #3 Name

First NameLast Name
DOB
Child #4 Name

First NameLast Name
DOB
The signature below hereby authorizes and requests the release of any and all records pertaining to the following:
MedicalDentalSchoolDaycarePolice/Criminal RecordsProbation/Parole
Therapy/CounselingPsychiatry/PsychologicalCPSSubstance Abuse TreatmentOther
These items are to be provided to Lauren Gordon, LCSW with North Texas Family Services for the purpose of a court ordered evaluation. This consent is valid for one year from the date of signing. The client grants authorization for the release of records and will be responsible for the any fees incurred from the request.
Date

MonthDayYear
Date
Signature of Client for self and minor children

Clear
Signature of Guardian or Personal RepresentativeDate

* If you are signing as a personal representative of another individual please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc
Should be Empty: