Atlanta Child Therapy, Inc.

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

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 Date ______________________________________________ Print Name