Consent for Release of Information
Authorize Start Bright to release, obtain, or communicate confidential information regarding your minor child.
Child's First and Last Name
First Name
Last Name
Parent/Legal Guardian's First and Last 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
List the names of providers, agencies, or persons included on this consent. Click "Add row" to add more entries.
Parent/Legal Guardian's Signature
Date of Signature
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: