Authorization to Release/Exchange Information The Student Advocacy Center staff respects a client's right to privacy. This release will be used to assist in educational planning to promote student success. The Student Advocacy Center of Michigan is authorized to release and exchange information aboutStudent Name(Required) with the following agencies (as applicable):School(s) and School District(s) / Public School Academy Name(Required) Authorized Agencies Community Mental Health Probation / Court / Juvenile Placement Michigan Alliance for Families Community Agency / Other (Enter below) Agency NamesInformation that can be released and exchanged by fax or email may include:General education records, including grades, credits earned, disciplinary records, and referrals to outside agencies. Special education records such as MET, IEPs, MDRS, and any functional behavior assessments or behavior intervention plans. Treatment information including, but not limited to: diagnoses, services provided, number of sessions, progress, medications with dosages, reports. Any psychological evaluations, psychiatric reports, and/or progress reports.If you would like to authorize the release of additional information, please describe below:Additional Information to ReleaseSignature(Required)Name Printed(Required) Date(Required) MM slash DD slash YYYY **This consent is voluntary and subject to revocation at any time. **The content of the release has been explained to me.
