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Worksheet

Authorization for Release of Information

1. ➜

Authorization Form

Please fill out an individual worksheet for each professional (pediatrician, therapist, OT, PT, SLP, etc) you or your child are currently seeing. 

2. ➜

I, (Parent/Guardian Name)

3. ➜

Authorize the following individual or organization: (name of doctor/therapist/etc.)

4. ➜

Address

5. ➜

Email and Phone Number

6. ➜

To release information regarding my child or children: (full names)

7. ➜

To:

Susan L Morley, ECE, CLPC, CPS-AD
Parent Coach Atlanta, LLC
117 Hood Cir., Decatur, GA 30030

404-429-7201

8. ➜

I authorize the release of any and all records pertaining to the child/children’s social, emotional, medical, cognitive, and academic functioning within the educational and/or home environment. Signed,

9. ➜

Date