Consent for Release of Information
Authorize Start Bright Therapy to release, obtain, or communicate confidential information regarding your minor child.
Parent/Legal Guardian's Full Name
First Name
Last Name
Client's Full Name
First Name
Last Name
I give Start Bright Therapy permission to:
Release confidential records
Obtain confidential records
Verbally communicate with
Other (please specify below)
If you selected 'Other', please specify:
This consent is valid through:
Specific end date (please specify below)
End of therapy services
If you selected 'Specific end date', please enter the date:
-
Month
-
Day
Year
Date
Please list providers, agencies, or persons included on this consent. (Click 'Add' to enter more than one) Fields: Name, Phone Number, Address
Parent/Legal Guardian's Signature
Date of Signature
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: