CLIENT NAME:DOB:
This Consent Authorizes:
Orlando Counseling Center for Children, Families and Adults P.A.
540 E. Horatio, Suite 202
Maitland, Florida 32751
407-975-0400
To exchange confidential information concerning the above named client with the following agencies:
Referral Source:
Contracting Agency:
School System: County School System
Other Involved
Treatment Agencies:
Physician:
All of the following information is authorized for release through verbal communication for the purpose of assessment and treatment coordination:
Psychoeducational AssessmentHearing Screening Individualized Treatment Plan
Behavioral Report Immunization Record Psychosocial Evaluation
Special Report Neurology Report Behavioral Program
Psychological EvaluationPsychiatric Evaluation Discharge Summary
Medication Management Visits Progress Notes
I understand that these records contain psychiatric and/or drug and alcohol information. I also understand that these records may also contain references to blood-borne pathogens (e.g., HIV, AIDS). I understand that I may revoke this consent at any time, however I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES 1 YEAR AFTER SIGNATURE DATE BELOW.
CLIENT SIGNATURE: DATE:
PARENT/ GUARDIAN: DATE:
WITNESS: DATE:
