I understand that to receive services, it is an inter-agency collaboration and that information about my child and family will be shared between needed agencies for
support, planning, and developmental. This includes my local Community Center Board, State agencies, Contractors, and Inter-Disciplinarian team members.
I hereby authorize the mutual exchange of information regarding the named person and the agencies / individuals listed on this form. INCLUDING, NOTES, CLIENT DETAILS, PHOTOS, VIDEOS, OTHER WORK SAMPLES, AND PROFESSIONAL OPINIONS.
There is a focus on trans-disciplinarian teamwork, this means that professional from different backgrounds will discuss different details and strategies to improve services.
I have been fully informed of the intended use of this information sharing. I also understand that the agency / person receiving this information is obliged to maintain it in a confidential manner and it is to be used only for the purpose I have authorized. I understand that this information will be kept in a database that is password protected,and for the exclusive goal of optimizing communication, resources, and supports for (myself, child, and / or family).