AUTHORIZATION FOR DISCLOSURE OF EDUCATIONAL INFORMATION
I, ______(Parent, Guardian, Legal Representative), authorize the exchange, disclosure or release of information on:______(Student), SS# ______, DOB______between the following entities (This allows both parties to provide and receive information from one another):
______(school district) ACES
______(address) 1212 A S. Main
______Maryville, MO 64468
______(phone) 660-582-3768
THE PURPOSE OF THIS DISCLOSURE IS:
To share/refer information to obtain services consistent with the ACES program
THE SPECIFIC INFORMATION TO BE DISCLOSED/RELEASED IS (CHECK ALL THAT APPLY)
Educational Records Exchange of information via telephone/email
1. / READ CAREFULLY: I understand that my educational information records are confidential. I understand that by signing this authorization, I am allowing the release of my educational information.2. / This authorization includes both information presently compiled and information to be compiled during the course of treatment at the above named facility or agency paying for services during the specified time frame.
3. / This authorization becomes effective on:
4. / I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so IN WRITING and present my written revocation to the school administrator or ACES social worker at the facility. I further understand that actions already taken based on this authorization, prior to revocation, will not be affected.
5. / I understand that I have the right to receive a copy of this authorization. A photographic copy of this authorization is as valid as the original.
6. / I understand that authorizing the disclosure of this educational information is voluntary. I can refuse to sign this authorization.
Signature of student: / Date:
Witness: / Date:
Signature of Parent/Legal Guardian/Representative / Date:
ACES SCHOOL SOCIAL WORK
INFORMED CONSENT CONTRACT
Name of Student ______
Confidentiality: Please understand that all records, written information, or any electronic data are keptCONFIDENTIAL. All school social work services are confidential, except those required by law to report, which include the following:
-- threats of harm to another or oneself
-- domestic violence
-- child or elder abuse
-- by court order
The other exception would be when a signed release has been obtained to provide or receive information from another entity.
School social work services are focused on assisting with concerns and behaviors of a student that could impede their success. These may include individual sessions as well as group sessions, observations, collaboration with staff, and intervention strategies. You have the right to end this service at any time. The school social worker has a form available if you decide to discontinue this service. These services will continue until revoked by the parent or discontinued by the school.
As a social worker, I participate in case consultations and supervision in accordance with accepted professional behavior.
In counseling children or adolescents, confidentiality is a necessity; as much as possible, in order for the therapeutic process to work. While you as parent or guardian have a legal right to information, I will speak with you in a general way unless there is a danger to the child’s life. This is conveyed to the child as well.
Permission to treat: I acknowledge that it is my choice to have my child participate in school social work services.
Your signature acknowledges agreement and understanding. Please feel free to contact the social worker regarding any questions or concerns you may have.
______
Signature of Parent Date
______
Signature of Student Date
______
Signature of School Social Worker Date
Last updated 4/22/13