I, , request Interactive Counseling & Consulting Services Inc. to consult with the individual(s) listed below. I understand that such consultations will be conducted to assist in achieving the counseling goals and objectives, which I have set forth with my licensed professional.
I request Interactive Counseling & Consulting Services Inc. and the individual listed below to share information and records gathered through legal, medical, psychological, social evaluations, or consultations.
Individuals requested to share information and documents.
Name:
Agency:
Address:
City: State: Zip:
Telephone: FAX:
Email
Request for communication concerning children.
I verify that I am the legal parent, legal guardian, managing conservator, or a person designated by the court to have authority to consent to provide psychological services for the child(ren) listed below and I request Interactive Counseling & Consulting Services Inc. and those listed above to share information and documents regarding said children.
Child’s Name:
This is an electronic document for professional communication. An ink signature is not required or necessary. By typing your full name into both boxes you verify and agree that all information in this document is true and authorized by yourself. Interactive Counseling & Consulting Services will contact you to verify receipt of this electronic document.
[Signatures of adult requesting professional communication]
Adult Name Date:
Verify Adult Name Date:
Contact phone number
