Parental Release Form

Child/ren name/s

has my permission to participate in the services offered by Sarri Gilman, LMFT. It is my understanding that all client material is confidential and will not be released to any agency or person without the written permission of all family members participating, with some insurance requirement exceptions. The parents agree not to subpoena records or testimony for litigation purposes. In order to make the work with the child/ren more productive, the parents agree to not request information about the child’s individual private sessions with Sarri Gilman.

Parent/leagal guardian signature                                                       Date

Printed name_____________________________________phone_________________________

My last official parenting plan, date ______________, authorizes me with the right to authorize psychological services for the named child/ren.   ____yes  or  ____no

⇨Enclosed is a copy of the latest court order for the parenting coordinator

Mail to: Sarri Gilman, LMFT  742 Suzanne Court,  Langley  WA 98260