PATH PREVENTION AUTHORIZATION FOR      RELEASE OF INFORMATION FORM

The authorized parent or guardian gives permission to the P.A.T.H. Prevention Team (The Katallasso Group & TreeHouse of Scott County) to exchange, release, disclose, or obtain information and/or copies of all reports, records, and documents about themselves and their student receiving services within, to, or from the The Katallasso Group, TreeHouse of Scott County and their child's school district or other pertinent providers.

Purpose of Release: Acceptance for services at The Katalasso Group and/or TreeHouse Scott County

Disclosure & Consent Statement

I understand that the information disclosed to the recipient(s) may no longer be protected by privacy rules and may be subject to re-disclosure. Once released to The P.A.T.H. Prevention Team, the data may be defined as:

  • Court Services Data (Minnesota Statutes Section 13.84, subd. 1), and/or

  • Corrections and Detention Data (Minnesota Statutes Section 13.85, subd. 1).

As a result, it may be classified as public, private, or confidential data as defined by Minnesota Statutes, Section 13.02.

This release of information will allow The P.A.T.H. Prevention Team to access your student's:

  • Attendance records

  • Academic performance (grades)

  • Other relevant school information needed to support and serve your student effectively

We may use your student’s personal phone as one way to connect, provide reminders, offer encouragement, and maintain regular communication. To ensure accurate and organized documentation, we may also use a secure AI-powered tool to transcribe and summarize 1:1 meeting minutes for case note purposes only. These recordings are used solely for documentation and will not be shared or used for any other purpose.

I understand the following:

  • I may revoke this consent at any time, except to the extent that action has already been taken in reliance on it (e.g., probation, parole, supervised release, work release, etc.).

  • If I choose to revoke this consent before the expiration date, I must do so in writing and deliver it to the agency listed above.

  • This consent automatically expires upon discharge from supervision or one year from the most recent update shown below, whichever comes first.

  • I understand that I am not required to sign this authorization to release information, and the consequences of not signing have been explained to me.

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Student Name: 

(First/Middle/Last)

 *

Student Birthdate: 

(Month/Day/Year)

 *
Student School: *

Additional Providers Approved for Release of Information:

 (Children's Mental Health, Therapist, Doctor, etc.)

Parent or Guardian Name:

(First/Last)

 *
Parent or Guardian Email: *

Today’s Date: 

(Month/Day/Year)

 *
Parent or Guardian Signature: *
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