840 East River Place Ste 504

Your Family Clinic LLC 514 Old Richton Rd. Petal, Mississippi 39465 601-544-8935

Billing Address 67 Mars Hill Road Petal, MS 39465

AUTHORITY TO RELEASE OR OBTAIN INFORMATION

I (print name)______hereby consent to:  The exchange of information between: Your Family Clinic LLC / Dan Moore

(name of agency/individual releasing information):

(name of agency/individual receiving information):

For the specific purpose of coordination of services and ongoing treatment.  The release of any and all information pertaining to my treatment from:

(name of agency/individual releasing information):

To: Your Family Clinic, LLC Daniel T. Moore, Ph.D.

(name of agency/individual receiving information):

I specifically consent to release/obtain school records and/or mental health information pertaining to:

 Evaluations  504 Plan or IEP  Report Cards  Tier Placement  Diagnosis  Discipline Records  Psycho-Educational Testing  State Testing Results  Treatment Planning  Other______

I understand that I may revoke this consent at any time except to the extent that the action has been taken thereon. I further understand that this consent will expire (please check one): ____ when I am no longer receiving services from Dr. Dan Moore or my case has been closed.

____ on the following date ___/___/_____.

______Signature of Client or Legal Guardian Date

______Signature of Witness Date

Note to Program Receiving This Information:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of this person to whom it pertains or otherwise permitted by 42 CFR part 2. A general Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.