CAFL Consent to Evaluate - EI or PSE

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.

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
Evaluator/Agency
Other

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.