STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT County Petitioner Petition Number Respondent AUTHORIZATION FOR RELEASE OF PROTECTED EDUCATION INFORMATION Respondent Name: _________________________________ Date of Birth: ___________________ Address/Street: _____________________________________________ Apartment No.: ________ City/Town: ____________________________ State: ________________ Zip Code: ____________ I, ___________________________________, authorize the Rhode Island Family Court Mental (Parent/guardian/eligible student) Health Clinic to obtain confidential information from: School Address Telephone Facsimile Contact Person ________________________________________________________________ ________________________________________________________________ __________________________ __________________________ ________________________________________________________________ Check confidential information to be released or obtained: Complete educational record OR Specify records: Educational evaluations Assessments/treatment plans Telephone communications Educational/Individualized Education Plan (IEP) information Transcripts/report cards Information pertaining to my education Other (specify) § 504 information ___________________________________ Method of Release: Telephone/Verbal Photocopies Facsimile (401) 458-3128 The purpose of this information is for: Rhode Island Family Court Mental Health Clinic Assessment for review prior to the child/family's appointments with the clinic. PLEASE MAIL OR FAX ALL INFORMATION TO: Rhode Island Family Court Mental Health Clinic c/o Case Manager One Dorrance Plaza ­ Room 257 Providence, RI 02903 Page 1 of 2 FC-16 (revised January 2012) American LegalNet, Inc. www.FormsWorkFlow.com ___________________ Initials Parent/Guardian I have carefully read the above information and I voluntarily consent to disclosure of the indicated confidential educational records of my child ___________________________________. I understand that my child's records are protected under state and federal law and cannot be disclosed without my written consent unless otherwise provided for in the law. I understand that if I authorize the Rhode Island Family Court Mental Health Clinic to receive information from my child's school, the Clinic will not disclose it to others. I also understand that I may withdraw or revoke this consent in writing at any time and no further records will be released after that. I understand that my child's records are protected from release without my permission by the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g) and the Rhode Island Educational Records Bill of Rights (G.L. 1956 § 16-71-1 through § 16-71-5). The Rhode Island Educational Records Bill of Rights gives me and my child: " The right to have the records kept confidential and not released to any other individual, agency or organization without prior written consent of the parent, legal guardian, or eligible student, except to the extent that the release of the records is authorized by the provisions of 20 U.S.C. § 1232g or other applicable Rhode Island law or court process or procedures. This release expires automatically one (1) year from the date signed. Parent Signature: ________________________________________ Date: _____________________ OR Legal Guardian Signature: ________________________________ Date: _____________________ Relationship to Student: _____________________________________________________________ Witness Signature: _______________________________________ Date: _____________________ Page 2 of 2 FC-16 (revised January 2012) American LegalNet, Inc. www.FormsWorkFlow.com