RELEASE OF INFORMATION …

                                        RELEASE OF INFORMATION

                      St. Stephen's Episcopal School
                                              2900 Bunny Run, Austin, Texas 78746
                               phone: 512-327-1213 · fax: 512-327-6771 · email: admission@sstx.org

All information sent to Gemma M. Ainslie, Ph.D., consulting psychologist to St. Stephen's Episcopal School,
will be kept confidential. It will not become part of your child's permanent file.


Parent Section:
Please complete this form and forward it to the testing, counseling, guidance and/or psychotherapy
professional(s) who met with your child. Do not return this form to St. Stephen's.

I hereby authorize _____________________________________________ to forward all reports of testing,
                                                      PROFESSIONAL'S NAME

psychological assessment, diagnosis, treatment and recommendations as well as to discuss his/her contact relevant

to my child, ___________________________________ to Gemma M. Ainslie, Ph.D., consulting psychologist
                                     PRINT NAME OF APPLICANT


to St. Stephen's Episcopal School.

__________________________________________________________   _________________   ___________________________________________________
PRINT NAME OF APPLICANT                                      DATE                SIGNATURE OF PARENT OR GUARDIAN




Professional Section:
Upon receipt of the Release of Information form, please forward all reports of testing, psychological assessment,
diagnosis, treatment and recommendations to:

Gemma M. Ainslie, Ph.D.
5750 Balcones, Suite 111
Austin, TX 78731
Telephone: (512) 451-5678
Fax: (512) 472-9512

If you do not have any written reports, please call Dr. Ainslie so that she is aware you have received the release.
Dr. Ainslie or a member of the St. Stephen's counseling staff will contact you to discuss any relevant information regarding this student
after she receives his/her completed application and your written reports.
If you have any questions, please contact Dr. Ainslie at the number listed above.

           This form is to be mailed to the consulting professional - not St. Stephen's Episcopal School.