Request for student information and records - PresenceLearning

Part 2: Your Contact Information

Part 3: Student Information

Part 4: Purpose of the Request

Part 5: Authorization Notification

I hereby certify and verify I have express written consent to obtain information about the student for which this request is made. I have attached a copy of the written consent to this form.

I understand that the recipient of any record(s) will be used for legitimate interests only and that the information contained therein shall not be further transferred or communicated to any other party or agency without the expressed written consent of the student, parent/guardian except under authority of the Federal Educational Rights and Privacy Act (20 U.S.C. § 1232 g). I certify this information as complete and accurate.

I understand that an incomplete form will not be processed and will be considered closed after expiration of the 30 day notification window. I declare under that the foregoing is true and correct.

Part 1: Instructions

The information required on this form is necessary to verify and protect student records from being accessed by unauthorized individuals. The information contained in this request will be treated as confidential except where required otherwise by law.

Please complete all information in full and then finalize the process by submitting this form to or by fax to 844.811.6354.

You may also return this form and any attachments by mail to:

180 Montgomery Street
Suite 1800
San Francisco, CA 94104

Where applicable attach a copy of written consent to obtain information about the student for which this request is being made.

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© 2020. All Rights Reserved. | PresenceLearning makes live, online special education related services available to K-12 students around the country — and world. As the leader in the delivery of clinical services via the web, PresenceLearning has provided over two million sessions of speech-language therapy, occupational therapy, behavioral interventions and mental health services, assessments, and early childhood services.