I give consent for information regarding the above named student to be shared between Russell Coaching LLC and the professionals listed below by completing and submitting this form.

If you so choose, please list below the names of who Dr. Russell can contact for info and share information with, including student’s school, pediatrician, psychologist, and other specialists.

RUSSELL COACHING FOR STUDENTS, LLC

Release for Individuals Involved in Care

I confirm that I am completing this Release of Information for Russell Coaching for Students. Russell Coaching for Students has my permission to give and receive information from the individuals and organizations indicated below. If you do not wish to give permission, leave that field blank.

YES

Student's Name

First Name

Last Name

Student's Date of Birth

YYYY

If Y, name of school:

If Y, name of psychologist:

If Y, name of therapist:

If Y, name of pediatrician:

If Y, name of additional medical professional:

If Y, name of additional specialist:

For young adults (age 18 and older) do we have your permission to speak with your parents?

By completing this form, you give us permission to communicate with the above professionals. This consent is valid for five years or until I withdraw my consent in writing.

Parent/Guardian Name

First Name

Last Name

Date

YYYY

Russell Coaching for Students can be reached at 212-716-1161, drrussell@russellcoaching, and www.russellcoaching.com.

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