Consent for Release of Information and Referral

This form provides parental permission for the release of health, development and/or educational information between the Child Care Health Consultant (CCHC), the child care program staff and other individuals, programs or agencies that are working with the child and family in an effort to better understand and address their needs. In addition, this form obtains parental permission for the referral to needed support services for the child and/or family.

This form was developed through a collaboration between Abby J. Cohen, J.D. and CCHP.