Atlanta

Child Therapy, Inc.

Authorization to Release Confidential Information

I hereby authorize the release of confidential information from:

Atlanta Child Therapy, Inc.
2950 Cherokee Street, NW, Building 500
Kennesaw, Georgia 30144
I authorize the release of confidential information to:
__________________________ _________________________ _________________________
Name if Individual

Agency


Phone Number

I authorize the release of confidential information for the following time period:
Indefinitely
__________________ to ______________________



Start Date End Date

The release of confidential information is too facilitate planning for:
_____________________
Childs Last Name

_________________ __________
First

Middle

__________
Date of Birth

You are hereby authorized to release the following specified information that may include any available
third party records:
Psychological Evaluations

Medical Records

Permanent Records/Transcripts

Psychiatric Evaluations

Vocational Guidance Reports

Psycho-educational Evaluations

Speech and Language Evaluations

Audiological Reports

Occupational Therapy Evaluations

Staffing Reports

Physical Therapy Evaluations

Other ______________________________

I UNDERSTAND THAT THE GRANTING OF CONSENT FOR THE RELEASE OF RECORDS IS VOLUNTARY ON
MY PART.
______________________________________________
Client/Guardian Signature





______________________________________________
Print Name

__________________

Date

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506