Release of Consent Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client Name *Date of Birth*A separate Consent for Exchange of Information form must be completed for each individual or agency you wish for MNTC to communicate with. * I understand that my records are protected by data practice laws and cannot be released without my consent unless otherwise allowed by law. I understand that only the information and records indicated below will be released or obtained. I understand that this consent does not authorize the recipient of the information or records to re-disclose the information or records to any other person or facility unless authorized by law. I understand that the information will only be used for the purposes indicated below. I understand that I may withdraw or modify this consent at any time but that the revocation or modification will not affect any release of information that previously occurred. I understand that this consent expires and is no longer valid one year from the date it was signed. I understand that observation and/or assessment can take place in either setting. I Authorize: Clearbridge ABA 8609 Lyndale Ave S #213, Bloomington, MN 55420 Name of Staff: *To obtain records from or release records to: Name of AgencyName of StaffType of information released:Assessments or evaluationsEducational recordsBehavior reportsMedical recordsAllOtherInformation may be shared in person or by mail. I also give permission to share information using the following methods:PhoneEmailFaxAllOther Birth or information Parent or Guardian or Authorized Representatives Signature Clear Signature DateSubmit
