I hereby waive my right as parent/guardian to obtain information from and copies of any records from Lois Thomson-Bowersock, LCDC, ADC, ICADC and The Parents’ Coach pertaining to the evaluation and treatment of the following child:

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Child’s Name

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Child’s Date of Birth

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Child's Age

I understand that Lois Thomson-Bowersock, LCDC, ADC, ICADC and The Parents’ Coach may refuse to provide me, or any third party acting upon my request or authorization, with information and records pertaining to this child’s mental health evaluation and treatment, if disclosure in the opinion of the child’s therapist/counselor would negatively impact the child or the child’s evaluation and treatment. I hereby release Lois Thomson-Bowersock, LCDC, ADC, ICADC and The Parents’ Coach from any and all liability for good-faith refusal to disclose the child’s information or records.

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Parent or Guardian

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Date

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Parent or Guardian

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Date

As witnessed by:

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Lois Thomson-Bowersock. LCDC, ADC II,  CET

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Date

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