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To download a copy of our “School Release of Information Form” in a Microsoft Word document (.doc) version, simply click here.  The form will automatically download to your device or computer.

Please return your completed form by email to laurie@specialeducationguru.com

School Release of Information Form

Consent to Communication and Disclosure of School Student Records

Student Name: _________________________

Date of Birth: __________________

I give my consent for ______________________________________
(Name of educational Institution, Therapist, etc)
to disclose and communicate regarding any and all of the information set forth below to Dr. Laurie Hoke, Educational Concierge

Information to be disclosed to recipient:

The complete student record of ____________________________,
(Student Name)

(Please check all that apply)

Report Card ___

MTSS Forms ___

Case Study Evaluation ___

Eligibility/IEP Paperwork ___

504 Paperwork ___

Discipline Records ___


Permission for the aforementioned to speak to:

(Please check all that apply)

School Counselor/Social worker ___

School Psychologist ___

Teachers ___

Private Therapist ___

Private Tutor ___


This consent is valid for one calendar year from the date set forth below, and may be revoked at any time in writing. I also understand that I have the right to inspect and copy the information to be disclosed pursuant to this consent.

Parent/Guardian’s Signature: _____________________

Witness: _________________________

Date: ___________________________

Student’s Signature: __________________________

Date: ___________________________

Note: If the student is under age 12, only the parent’s signature is needed. If the student is between ages 12 and 18, both the parent’s and student’s signature are needed. If the student is age 18 or over, only the student’s (or if the student has been judged to be incapacitated by a court, the guardian’s) signature is required.