Authorization to Release Information

Section one: please provide your name and information, or the information about your child. If you have more than one child involved, please complete one form for each of the minor children. 

Section two: provide the information of the agency, healthcare provider, school, daycare, therapist, attorney, or any other professional you wish me to speak with. You must provide their fax number and/or their email address.  It is not sufficient to only provide an address and phone number.  If you do not know, please contact the appropriate office to obtain that information. The social investigator’s office will not look up or obtain the contact information for you. 

I hereby authorize the below named agency to obtain and release from the following:

Information is being provided to: 

Dr. Tracy Riley, LCSW
3410 Kori Road
Jacksonville, Florida 32257
866-384-3669—fax or Tracy@TracyRiley.com

Section three: Sign, print your name, and date the form. Click submit. 

All records, evaluations, and documents to include medical, mental health, and/or substance abuse information.  

This authorization will expire one year from the date of my signature below.  I understand that I can revoke this authorization at any time by writing to the healthcare provider.  

I understand that this Release of Information authorizes Tracy Riley Counseling and its designated professionals to obtain, exchange, and/or disclose information for the purposes of conducting a social investigation, as well as for providing reunification therapy and/or parenting coordination services. I further understand that any records obtained may be used to support the assessment, recommendations, treatment planning, coordination of services, and overall case management associated with any of these professional roles. I acknowledge that information shared across these services may be utilized to ensure continuity of care, promote the best interests of the child, and fulfill the responsibilities outlined by the court or referring party.  

I have read and understand the nature of this release.  I willingly give my consent.