ROI Parent & Family Coaching Services

Please complete this form for EACH professional you are currently working with.

By completing the information below and checking the box at the end, I authorize Susan Morley / Parent Coach Atlanta to communicate directly with the professional listed for the purpose of coordination of care, consultation, and collaborative support related to parenting and family coaching services.

Please provide the answers in section 3 below:

1. Name
2. Phone number
3. Email

Provide the answers in section 5 below

1. Practice/Organization
2. Role (e.g., therapist, pediatrician, school counselor, educational consultant): 

1. Name
2. Phone Number: 
3. Email Address: 

Enter each child's name and age.

Susan L Morley, ECE, CLPC, CPS-AD
Parent Coach Atlanta, LLC
404-429-7201

I understand that communication with the professional listed above may include:

• Parenting strategies and recommendations

• Behavioral patterns and observations

• Emotional regulation concerns at home and/or school

• School-related concerns (behavior, communication, supports, suspensions, accommodations)

• General progress updates related to coaching goals

• Professional consultation and care coordination

Psychotherapy notes will not be requested or disclosed.

I understand that:

• This authorization applies only to the professional listed above.

• If I am working with multiple professionals, I will complete a separate authorization for each.

• Information shared will be limited to what is reasonably necessary for collaboration and support.

• I may revoke this authorization at any time by notifying Parent Coach Atlanta in writing.

• This authorization remains in effect until I revoke it or until my services with Parent Coach Atlanta end.

I confirm that the professional information above is accurate and I give my permission for Parent Coach Atlanta to contact this professional for the purposes described.