Two Way ROI: Release of Information
Allowing for Greater Collaboration and Continuity of Care between Providers
Please list the important people in you or your child's support team that you'd like us to collaborate with as we do the evaluation.
(Teachers, Psychiatrists, Pediatricians, Speech Therapists, School Counselors, Therapists, etc.)
Provider Information
First Name
Last Name
Providers Email Address
example@example.com
Information to be released from Provider 1
All Records
Clinical Notes
Diagnostic Testing Results
Treatment Plan
Personal Reference (Adults only)
First Name
Last Name
Personal Reference email address
example@example.com
Information to be released from Provider 2
All Records
Clinical Notes
Diagnotic Testing Results
Treatment Plan
Teacher Reference (Child Only)
First Name
Last Name
Email
example@example.com
Information to be released
All Records
Clinical Notes
Diagnostic Testing Results
Treatment Plan
This form provides Mindful Paths with written permission to communicate with the individuals listed below and those individuals to communicate with us regarding you or your child's treatment. This release will be valid for up to one year from date of signature
I consent
I do not consent
Signature
*
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Month
-
Day
Year
Date
Please Type your Full Name
Full Name
Continue
Continue
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