AUTHORIZATION FOR RELEASE OF INFORMATION

CLIENT NAME:___________________________________________________   DOB: ________________________

SSN: _________________________________________                SEX: MALE ________   FEMALE _________

I authorize FTS to exchange with, release to, or receive from, information concerning _____________________________

                                                                                                                                                                             Name of client

with__________________________________________________________________________________________

Name of Person, Agency or Organization

   ______________________________________________________________________________________________

City                             State             Zip Code                                                        Telephone

Information to consist of the following:

                ___ Discharge Summary                                     ___ School Records                            ___ Social History

                ___ Medical History and Physical                    ___ Ongoing Status                            ___ Psychiatric Evaluation

                ___ Mental Status                                               ___ Other (Please Specify)__________________

                                                                                                                                              __________________

PURPOSE FOR RELEASE OF INFORMATION

                ___ Continuation of Care                                   ___ Educational Planning  ___ Treatment Planning

                ___ Monitoring Treatment Progress                ___Client Assessment                        ___ Other ___________

                                                                                                                                                                ____________________

This consent will automatically terminate on ____________ unless revoked by the undersigned in writing prior to this date.    (Date not to exceed one year)

_______________________________________________                                 ______________________________

Client Signature                                                                                                                                                      Date

_______________________________________________                                 ______________________________

Legal Guardian/Parent                                                                                                                                           Date

_______________________________________________                                 ______________________________

Witness                                                                                                                                                                    Date