AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION

Parents, to expedite the BrainSTEPS consultation and training support services for your child, please fill out & sign the Parent Consent Form below after an online referral is made. This consent form provides your authorization to request/release confidential information about your child to and from BrainSTEPS.

Disclosure of Information Protected by the Family Educational Rights and Privacy Act by:

Pursuant to the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 C.F.R. part 99), the written consent of a parent or eligible student is required before the education records of a student, or personally identifiable information contained therein, may be disclosed to a third party unless an exception to this general requirement of written consent applies. If a student is age 18 years or older, or is enrolled in an institution of postsecondary education, he or she is an “eligible student” and must provide written consent for the disclosure of his or her education records or personally identifiable information contained therein.

Parent/Guardian Email Address

Parent/Guardian Phone

hereby agree to allow the Intermediate Unit BrainSTEPS Team listed above to disclose the following personally identifiable information or education records pertaining to the student listed below, including records that are collected by the BrainSTEPS team. This includes records obtained from the parent such as medical information, educational records obtained from the parent or the school, BrainSTEPS created educational recommendations, school observation information, and Brain Injury Support Framework support recommendations for:

Name of Student

to the

for the purpose of BrainSTEPS consultation and training.

By signing this form, you are also providing consent for the Intermediate Unit BrainSTEPS team to:
1. provide consultation and training support on behalf of your child to your child’s school team;
2. input your child’s required referral information, consultation activities, and related information into the BrainSTEPS Program database, which is a secure site.

I understand that following the initial BrainSTEPS consultation and training, someone from the BrainSTEPS Program will contact me annually until my child graduates from high school to determine if my child is experiencing any new or worsening brain injury-related learning issues as they age so that your child may benefit from additional BrainSTEPS support.

I understand that this authorization/permission to share information does not expire. You may withdraw your consent to share this information at any time. A request to withdraw your consent should be submitted in writing, signed, and sent to the BrainSTEPS Director, Dr. Brenda Eagan-Johnson at [email protected].

Signature

Signature of Parent, Guardian, or Eligible Student

Date

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File

Max. file size: 200 MB.

AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION

AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION

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