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Submitted on Aug 25, 2026 at 1:08 AM

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Guardian ad Litem Investigation Authorization

Case Name^*

Case Number^*

Court^*

Parent/Participant Name^*

Date of Birth^*

Child(ren)^*

Address^*

Country

Street address

Apartment, suite, etc.

Phone^*

Email^*

Authorization

I hereby authorize any individual, agency, organization, facility, school, employer, health care provider, mental health provider, governmental agency, or other custodian of records to release information to Tracy Riley, PsyD, LCSW, Court-Appointed Guardian ad Litem, or her authorized staff, for the sole purpose of completing the court-ordered Guardian ad Litem investigation, subject to the Court's Order of Appointment and applicable law.

Authorization to Communicate

I further authorize the Guardian ad Litem to communicate with the above individuals and entities to clarify records, discuss treatment, services, observations, and other matters relevant to the best interests of the child(ren), consistent with applicable law and the Court's appointment.

Method of Disclosure

Records may be released by secure email, encrypted electronic transmission, mail, fax, hand delivery, or other secure means permitted by law.

Expiration and Revocation

This authorization shall remain in effect until the earlier of: (1) the conclusion of the Guardian ad Litem appointment; (2) further order of the Court; or (3) one (1) year from the date of signature, unless a shorter period is required by law. I understand I may revoke this authorization in writing to the extent permitted by law; however, any information already released in reliance on this authorization will not be affected.

Acknowledgments^*

I understand this authorization is for a court-appointed Guardian ad Litem investigation.

I understand records obtained may be reviewed, summarized, and referenced in reports or testimony as permitted by law.

I understand this authorization does not require any provider to disclose information prohibited by law without additional authorization or court order.

I have had the opportunity to ask questions regarding this authorization.

Participant Name^*

Email^*

Signature^*

Sign here

Date^*

Attorney (if represented)^*

Receiving Provider: Dr. Tracy Riley, LCSW, CFMHE 3410 Kori Road, Jacksonville, FL 32257 P: 904-704-2527 | F: 866-384-3669 [email protected]^*

Receiving Provider:
Dr. Tracy Riley, LCSW, CFMHE
3410 Kori Road, Jacksonville, FL 32257
P: 904-704-2527 | F: 866-384-3669
tracy@tracyriley.com

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