Parent / Guardian Consent for Services
Student Information
Setting & Service
Authority to Consent
You represent and warrant that you have full legal authority under any applicable custody order, parenting plan, or guardianship order to consent to services for the student named above, and that your execution of this consent does not violate any such order. If decision-making authority is shared or limited in any way, you confirm that the other parent or guardian has been informed and either joins in this consent by signing this form or, under the applicable order, your consent alone is sufficient. You agree to provide a complete copy of any order limiting or defining your decision-making authority at least three business days before services begin, or immediately upon request. You acknowledge that Kristen Beckley, LLC may delay, suspend, or decline services until such documentation is received and/or verified. You agree to indemnify, defend, and hold harmless Kristen Beckley, LLC and the Qualified Examiner from and against any claims, demands, damages, liabilities, costs and expenses, including reasonably attorneys' fees, arising out of or relating to any breach of the representations herein or any dispute regarding your authority to consent.
Confidentiality — Required Disclosures
Information from these services is confidential. You acknowledge and agree that Kristen Beckley, LLC and/or the Qualified Examiner must or may release information without parent consent in these situations: suspected child abuse or neglect, mandated report under NH RSA 169-C:29; imminent risk of serious harm to self or others; valid court order or subpoena.
Release of the Final Report
You authorize Kristen Beckley, LLC to share the final report with the signing parent or guardian and, when services are contracted by a school or district, with that contracting school or district. Release to any other party requires your separate written authorization.
Two-Way Exchange with Outside Providers, Optional
You authorize Kristen Beckley, LLC to communicate with and exchange relevant information, verbally or in writing, with any provider identified in writing below for the purpose of these services. Information exchanged may include diagnoses, treatment summaries, behavioral observations, prior evaluations, and educational/medical records relevant to the work. This authorization expires one year from the date signed and may be revoked by you in writing at any time, except to the extent actions have already been taken in reliance on it.
Acknowledgment & Voluntary Consent
You were able to ask questions and receive answers to your satisfaction. Your child's participation is voluntary; you may withdraw consent in writing at any time before services are complete. You authorize Kristen Beckley, LLC to provide the services indicated above.