Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court

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STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
FAMILY COURT
County
Petition Number
Petitioner
Respondent
AUTHORIZATION FOR RELEASE OF PROTECTED EDUCATION INFORMATION
Respondent Name: _________________________________ Date of Birth: ___________________
Address/Street: _____________________________________________ Apartment No.: ________
City/Town: ____________________________ State: ________________ Zip Code: ____________
I, ___________________________________, authorize the Rhode Island Family Court Mental
(Parent/guardian/eligible student)
Health Clinic to obtain confidential information from:
School
________________________________________________________________
Address
________________________________________________________________
Telephone
__________________________
Facsimile
__________________________
Contact Person
________________________________________________________________
Check confidential information to be released or obtained:
 Complete educational record OR
Specify records:
 Educational evaluations
 Assessments/treatment plans
 Telephone communications
 Educational/Individualized Education Plan
(IEP) information
 Transcripts/report cards
 Information pertaining to my education
 Other (specify)
 § 504 information
___________________________________
Method of Release:  Telephone/Verbal
 Photocopies
 Facsimile (401) 458-3128
The purpose of this information is for: Rhode Island Family Court Mental Health Clinic
Assessment for review prior to the child/family’s appointments with the clinic.
PLEASE MAIL OR FAX ALL INFORMATION TO:
Rhode Island Family Court Mental Health Clinic
c/o Case Manager
One Dorrance Plaza – Room 257
___________________
Providence, RI 02903
Initials Parent/Guardian
Page 1 of 2
FC-16 (revised January 2012)

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