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Multi-System Youth

Consent for Release of Information

Complete this consent on screen, then print it or save it as a PDF to sign. This authorizes the agencies you select to exchange information in order to develop coordinated service goals for your child and family. Return the signed form to your MSY Coordinator or email msyreferrals@fairfieldcountyohio.gov.

Original form (PDF)
Child Information
Authorization

As the parent / legal guardian of the above-named child, I authorize the agencies and organizations selected below to exchange information regarding case history, psychological and educational assessments, treatment, and progress updates, in order to develop comprehensive service coordination goals that meet the needs of this child and/or family. Information released under this authorization may be subject to re-disclosure by the recipient.

Agencies & Organizations Authorized

Select each agency or organization authorized to exchange information:

School

Select the child's school district / building:

Signature

I understand that I may revoke my consent to release information at any time.

For Office Use Only — Revocation of Consent

Sign in this area only to revoke permission. I hereby revoke the above consent for release of information. Upon revocation, further release of specified information shall cease immediately.

Return the signed Consent for Release of Information to your MSY Coordinator, email msyreferrals@fairfieldcountyohio.gov, or fax to (740) 681-5540.