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Dream a Dream T.H. Consent to Release Information

This form is to be used when you are authorizing a person or facility to release information to D.a.D.T.H. or if you are authorizing D.a.D.T.H. release information to another person or facility.

I hereby authorize:

Person or Facility

To release information from the records of:

First name*

Last name*

Date of Birth*

Month

Day

Year

This information is to be released to:

Center or Therapist's Name

For the purpose of developing an equine activity program for the above-named participant. The information to be released is indicated below:

Choose all that apply:*

Medical History

Physical Therapy evaluation, assessment and program plan

Occupational Therapy evaluation, assessment and program plan

Speech Therapy evaluation, assessment and program plan

Mental Health diagnosis and treatment plan

Individual Habilitation Plan (I.H.P.)

Classroom Individual Education Plan (I.E.P.)

Psychosocial evaluation, assessment and program plan

Cognitive-Behavioral Management Plan

Other (explain below)

Other

This release is valid for one year and can be revoked, in writing, at my request.

Signature*

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Print Name*

Date*

Month

Day

Year

Relationship to Participant:*

Please send materials to:

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23650 Round Mountain Circle

Leander, TX 78641

info@dadth.org

512-2605957

Opening Hours:

Mon - Fri: 5pm-7:30pm

Saturday: 8am - 5pm

Sunday: Closed

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Dream a Dream T.H. Consent to Release Information

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