Chapter 18 - EXHIBIT 18J • CONSENT TO RELEASE AND EXCHANGE CONFIDENTIAL AND PRIVILEGED INFORMATION

• Jurisdiction: Colorado

EXHIBIT 18J • CONSENT TO RELEASE AND EXCHANGE CONFIDENTIAL AND PRIVILEGED INFORMATION

CONSENT TO RELEASE AND EXCHANGE CONFIDENTIAL AND PRIVILEGED INFORMATION

Name of Client: __________
Children's Names and Ages: __________
Your relationship to the children listed above: __________

CONSENT TO RELEASE INFORMATION: As a part of the Court ordered services currently being conducted concerning my children, I understand that__________and the professionals and members of __________, consult with other professionals who I and/or members of my family have had some type of professional contact. I hereby authorize the persons or institutions listed below to release information and to exchange information with__________and_ office. I understand that this consent applies to information derived from any psychological, counseling, psychiatric, medical, education/school, day care and/or other professional contacts. I understand that the information released would include the results of diagnostic tests and the records of any medical, psychological, psychotherapy, counseling, and/or psychiatric treatment rendered to me and/or the about listed children. I understand that the information released may include the notes and results of psychological evaluations, notes from psychotherapy sessions, and any opinions derived from these procedures. I understand that the information may be released to __________ and her office, verbally, in writing, or both. I understand that this consent applies to information derived from any schools or day care and may include any educational, social, and behavioral information and observations. I understand that this consent applies to the sharing of information, opinions, and observations the listed professional below has had regarding their contacts with me, and/or with any...