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Submitted on Aug 30, 2026 at 3:50 PM

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Authorization for Release of Information

Person/Parent Authorizing Release^*

Date of Birth^*

Phone Number^*

Email Address^*

Ward/Child's Name^*

Ward/Child's Date of Birth^*

Relationship to Ward/Child^*

Case Name/Number^*

PROVIDER AUTHORIZED TO RELEASE INFORMATION

Provider Name^*

Contact Person^*

Phone^*

Fax^*

Email^*

Address^*

Street address

Other (please specify)

RECORDS AUTHORIZED FOR RELEASE

Other (please specify)

AUTHORIZATION

I authorize the above provider to release records and/or communicate directly with Dr. Tracy Riley, LCSW, CFMHE, for purposes of a Social Investigation, parenting evaluation, custody-related matter, or other forensic family law proceeding.

Both Records and Verbal Communication^*

Records may be transmitted by secure email, fax, mail, electronic portal, or other customary means. Information disclosed pursuant to this authorization may become part of a court proceeding and may no longer be protected by federal privacy regulations.

EXPIRATION

One Year From Signature^*

I understand that I may revoke this authorization at any time in writing, except to the extent action has already been taken in reliance upon it.

Signature^*

Sign here

Printed Name^*

Date^*

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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