Professional Christian Counseling
Parental Release of Information
Permission for the Release of Your Child's Information. By completing and sending the form below, I grant permission for Counselworx™ and it's counselors to receive and share information with the people and institutions I designate in the box below. I understand that sending this information constitutes acceptance of these Counselworx™ policies. I further understand that this communication may include psychological, social, academic, medical, legal, testing and psychiatric information. I understand that the purpose of this communication is for facilitating my child’s services at Counselworx™. I understand this agreement will be in effect until a period of 90 days following the end of my child’s services with Counselworx™. I also understand that this agreement may be ended at any time by my written notice.
Include the names of all other adults who know your child and to whom you wish for your Counselworx™ Counselor to be able to share and receive information with such as: noncustodial parents, school teachers and pastors. If no other persons are privileged to information about your child or have nothing to the knowledge of your child please leave blank.