|
Bend Psychological Services
&
Education Options
965 NE Wiest Way
Bend, Oregon 97701
Telephone & : (541)
388-5660
Release of
Information - Child
Child's Full Name:
______________________________________________________________
(name)
Child's Date Of Birth: ___________________________
SSN:
_______________________________
Release of Information From :
__________________________________________________________________
(organization or name of person
who has the requested information)
Release of Information To:
Dr.
Michael Conner
&
(others: )____________________________
(organization or name of
person)
Purpose: The purpose of
this release is to facilitate educational, assessment, referral and
treatment planning.
Permissions Granted For Requested
Information: The following
permissions will be in effect until December 31, 2002:
- To communicate verbally and in writing
to and from Bend Psychological Services & Education Options.
- Release records requested below
- School Records
- Mental Health Evaluations
- Mental health admission/evaluation
- Treatment Plan
- Discharge Summary
- Other:
________________________________________________
_______________________________________
(print name)
Parent/Legal Guardian |
____________________
(contact phone number)
|
_______________________________________
(signature)
Parent/Legal Guardian Name
________________________________________
Patient name (minor)
________________________________________
Patient Signature (minor)
_____________________________
Date Of Release
|