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AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION

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

Parent/Guardian/Surrogate
Street
City / State / Zip

*If you do not know what Intermediate Unit (IU) provides services to your county:
1. Click “ABOUT US” in the menu above.
2. From the dropdown menu, choose “FIND YOUR BRAINSTEPS TEAM.”
3. Search for the correct Intermediate Unit BrainSTEPS name by county that your child lives in.

to obtain/release records and information regarding my child, as well as conduct a school day observation of my child if BrainSTEPS determines it is needed:
Student Name
Student Date of Birth
Parent/Guardian/Surrogate Phone Number
Parent/Guardian/Surrogate Email
Please include name, phone number, fax number for the following as appropriate:

Place an X below to designate specific reports, records, and/or phone contact to be released to your child’s BrainSTEPS Team:

This authorization/permission to share information does not expire. I understand that my child’s BrainSTEPS team will work with my child’s school team to determine brain injury-related school supports. I also understand that my signature provides consent for my child’s referral information, consultation activities, and related information to be entered into the BrainSTEPS Program’s database, which is a secure site.

Signature of Parent/Guardian/Surrogate
Date

AUTHORIZATION TO REQUEST/RELEASE CONFIDENTIAL INFORMATION

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

TO
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:
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 brenda@brainsteps.net.
Signature of Parent, Guardian, or Eligible Student
MM slash DD slash YYYY
Pennsylvania’s BrainSTEPS (Strategies Teaching Educators, Parents, and Students) Brain Injury School Re-Entry Consulting Program is in its 16th year of assisting school districts.

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