Student Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Phone

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I agree for the following agency/individual to release records to Hill Country School Psychology Services *

First Name

Last Name

Phone

(###)

###

####

Reason records are needed: *

Psychoeducational Evaluation

Speech and Language Evaluation

Consult

The Release is Effective Until *

(Typically releases are effective for one month.)

MM

DD

YYYY

The Following Records are Authorized for Release *

Regular Education Records

Medical/Health Records

Sociological/Developmental Information

Report of Vision/Hearing

Psychological/Individual Reports

Special Education Records

Psychiatric Reports

Counseling/Therapy Reports

Speech/Language Evaluation

Other

I approve verbal communication with the above designated individual/agency to facilitate assessment, coordination of services and/or treatment. *

Yes

No