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Consent Form

A *Consent Form (Word)Opens a new browser window. must be used to obtain parent/guardian permission to share information with other providers. This is one example of a consent form that can be used that is HIPAA complaint (see HIPAA checklist (PDF)Opens a new browser window. ). Many of the tools included on this website involve sharing information between various early childhood providers; therefore, it is important that families understand that this sharing of information is voluntary and requires their permission with a consent form. 

  • A signed *Consent Form can allow providers to share important information that may help obtain support and services for a child and family.
  • Explain to families that signing the *Consent Form is voluntary and will not affect their ability to receive services from your agency.
  • Explain to families that they can withdraw their consent at any time.
  • Make sure parents indicate what information can be released by checking off the appropriate item(s) (school records, medical information, etc.) on the form.
  • Make sure parents indicate the person(s) and/or agency(ies) permitted to exchange information by checking off the appropriate agency(ies) (school district, healthcare, etc) on the form.
  • Make sure that the sections requesting agency and providing agency are completed with as much contact information as possible should either agency need to contact one another.
  • *For children in foster care, consent forms may be specific to local county practice.

    AlertSpecial confidentiality issues related to mental health problems may need to be considered before sharing of information. The example consent form does address release of information pertaining to mental health diagnosis, or treatment, or psychological information (Welfare & Institutions code, §§5328, et seq).

    Last modified on: 12/16/2009 12:28 PM