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Release of Information

Solutions Parenting Support
Parent Coaching and Transitional Services

AUTHORIZATION TO RELEASE INFORMATION TO SOLUTIONS PARENTING SUPPORT & Hilary Moses, Transitional Specialist/Parent Coach

  • I hereby authorize the release and disclosure of any records (including any information related to medical, psychological, social, academics, psychiatric, drug and/or alcohol abuse, diagnosis, treatment, prognosis, and or therapy) therein contained.
    Purpose: The client’s identifiable health information received pursuant to this release authorization is to be used for the following purposes: Treatment overview and recommendations of said client, their family system and will not be released to anyone but Solutions Parenting Support.
  • This field is for validation purposes and should be left unchanged.