Consent to Release and Exchange Information
At Growing Nurtured Minds, we believe that collaboration between families, educators, and outside providers is essential for nurturing each child's growth. In order to best support your child’s cognitive, emotional, and behavioral development, we sometimes need to communicate and share relevant information with other professionals involved in your child's care. By signing this form, you are giving Growing Nurtured Minds permission to exchange relevant educational, developmental, behavioral, and/or medical information with the designated providers. This information will be used solely to coordinate services, plan interventions, monitor progress, and ensure that your child’s support team is working collaboratively toward shared goals. We take the confidentiality of your child’s information very seriously and will only share what is necessary to provide the best care. If you have any questions about this form or how information will be shared, please feel free to contact us. We are committed to maintaining the confidentiality, safety, and well-being of every child we serve. Growing Nurtured Minds www.growingnurturedminds.com info@growingnurturedminds.com 973-326-0003
Child's Full Name
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Child's Date of Birth
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Parent's Full Name
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I hereby authorize Growing Nurtured Minds to communicate with and release/obtain information to/from the following individual(s) or organization(s):
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Yes
No
Name of Provider/Agency:
Role (e.g., Therapist, Pediatrician, Neurologist):
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Phone Number & Email address:
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Parent/Guardian Authorization: I understand that: This consent is voluntary and can be revoked at any time by providing written notice to Growing Nurtured Minds. Revocation does not affect information already shared prior to the revocation. Only information reasonably necessary for the stated purpose(s) will be shared. Information disclosed may no longer be protected by HIPAA or FERPA once released to the designated recipient(s). This consent expires one year from the date signed unless otherwise specified below.
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Yes
No
Signature and Date of Consent
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Submit
Should be Empty: