Clinical Associates
of the Finger Lakes

CAFL Consent to Evaluate - EI or PSE

CAFL Consent to Evaluate

Child's First Name:
Child's Last Name:
Date of Birth (MM/DD/YYYY):

I give my permission for Clinical Associates of the Finger Lakes (CAFL) to conduct a Multidisciplinary Evaluation.
I give my permission for the Evaluation Team from CAFL to obtain and use previously performed assessments in their evaluation.

Parental Consent to Use E-mail to Exchange Personally Identifiable Information

Please check the boxes that apply and print the names of the following individuals/agencies for whom you give consent:
Child's Pediatrician
Service Coordinator (or none)
School District
CPSE Chairperson
County Rep
Agency/Childcare Center

By checking the consent box and signing below, you have chosen to communicate, or have authorized others to communicate, personally identifiable information concerning your child’s evaluations by e-mail without the use of encryption.  Sending personally identifiable information by e-mail has a number of risks that you should be aware of prior to giving your permission.  These risks include, but are not limited to, the following:  E-mail can be forwarded and stored in electronic and paper format easily without prior knowledge of the parent; can be changed without the knowledge of the sender or receiver; can contain harmful viruses and other programs.  In addition, e-mail sent over the internet without encryption is not secure and can be intercepted by unknown third parties; back-up copies of e-mail may still exist even after the sender and receiver have deleted the messages; and employers and online service providers have a right to check e-mail sent through their systems.

Parental Acknowledgement and Agreement:  I acknowledge that I have read and understand the items above, which describe the inherent risks of using e-mail to communicate personally identifiable information.  If checked below, I authorize Clinical Associates of the Finger Lakes (CAFL) staff to communicate with me at my e-mail address, concerning my child’s evaluation and any other related matters.  Furthermore, I either allow or deny permission for the members of my child’s evaluation team to share and exchange information including communicating personally identifiable information concerning my child using both electronic (unencrypted e-mail) and non-electronic means with the individuals/ agencies indicated above.

I understand that this consent is subject to cancellation at any time.  This consent shall not be used for the release of confidential, HIV-related information without specified, additional consent.

I give consent.

Parent/Guardian's Full Name:
Parent/Guardian's Email Address:

By checking this box, I consent to the information contained in this form.  This represents my legal electronic signature.