FALK SCHOOL COUNSELING DEPARTMENT
RELEASE OF INFORMATION
Student Name_______________________________________________________________________________
First
Middle
Last
I hereby grant permission for:
Name__________________________________________________________________________________
Agency________________________________________________________________________________
Address_______________________________________________________________________________
____________________________________________________Phone_____________________________
to share assessment, evaluation, diagnosis, treatment, and post-treatment
recommendations with the Falk School Counselor.
Parent Signature
_________________________________________________________________________________________________
Parent Signature
_________________________________________________________________________________________________
Signature of School Official
_________________________________________________________________________________________________
This release of information covers the time period of:
________________________________________ to _______________________________________
(month/day/year)
(month/day/year)
The original signed release is sent to the agency. A copy remains in the student’s
Counseling Department file.