Consent to Release InformationCarol Benton / Optimize Life, LLCPlease read and complete the following information. Client Name * First Name Last Name Client Date of Birth * MM DD YYYY This Consent to Release information authorizes information from my records (or my child’s records) to be shared with the following individuals: * I give permission to Carol Benton / Optimize Life, LLC and the agency/school listed below to share the following information: * Educational Medical Psychological Psychiatric Social Psychometric Agency or School Name * Your Name * First Name Last Name Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Please check the box below I understand that this authorization is valid for six months from the date below. I also understand that this information may not be released to any other person or organization without my permission in writing. A photocopy of this authorization shall be considered valid. If consenting as legal guardian, please check the box below By checking this box, I agree that I am the legal guardian of the individual listed above. I affirm that I have read and agree to the terms above. Thank you!
