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Unformatted text preview: Signature of client Printed name Date Signature of parent/ Printed name Relationship Date guardian/representative I witnessed that the person understood the nature of this request/authorization and freely gave his or her consent, but was physically unable to provide a signature. Signature of witness Printed name Date q Copy for client or parent/guardian q Copy for source of records q Copy for recipient of records FORM 52. Request/authorization for release of evaluation information. Adapted from a form devised by Ruth H. Sosis, PhD, of Cincinnati, OH, and used by permission of Dr. Sosis.From The Paper Office . Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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- Spring '10