Release Of Information

Name of Client
Parent/Guardian Name
give my consent to Sharone Gilbert, Psy.D., clinical psychologist, to discuss and review any school records or information pertaining to
I understand that Dr. Gilbert may collaborate with other professionals to review and interpret results and that students under Dr. Gilbert’s supervision may be working with my child.
Dr. Gilbert may consult with the following professionals: (Please Initial)
- School Personnel
- Pediatrician/Physician
- Supportive Service Providers
- Legal Representative
- Licensed psychologists
- Supervised Graduate students/fellows
In addition, I give my consent for Sharone Gilbert, Psy.D, to observe my child, in his/her school setting.
His/Her school setting
Parent/Guardian (Digital Signature)
Date
MM slash DD slash YYYY