of the Finger Lakes
|CAFL Consent to Evaluate|
Child's First Name:
I give my permission for Clinical Associates of the Finger Lakes (CAFL) to conduct a Multidisciplinary 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:
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.