THE KATALLASSO GROUP

AUTHORIZATION FOR RELEASE OF INFORMATION FORM &

PARENT CONSENT FOR COMMUNICATION WITH MINORS FORM

The authorized parent or guardian gives permission to the The Katallasso Group 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, and their child's school district or other pertinent providers.

• Communicate electronically one-on-one with the minor named below for service-related purposes.

  
  

Purpose of Release: Acceptance for services at The Katallasso Group

I understand that my records are protected under the Minnesota Government Data Practices Act, Minnesota Statutes, Chapter 13, and cannot be disclosed without my written consent or unless otherwise provided by law. 

I understand that the information disclosed to the recipient(s) may no longer be protected by the privacy rules and may be subject to re-disclosure. After release to The Katallasso Group 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) and, as a result, may be classified as either public, private or confidential data as defined by the provisions of Minnesota Statutes, Section 13.02. 

Communication with Minors Related to Services: Parents can also provide permission to our staff (mediators and coaches) to electronically communicate with their child, this may include:

• text messages

• voice memos

• email

• phone calls

• other approved electronic platforms used by The Katallasso Group

  
  

These communications may be used for scheduling, check-ins, follow-up support, restorative work, coaching-related matters, and other service-related communication.

By signing below, I understand and agree that:

1. I give permission for The Katallasso Group to electronically communicate one-on-one with my child/minor in connection with services.

2. Electronic communications will be kept professional, service-related, and appropriate.

3. The Katallasso Group may archive, save, and retain electronic communications with my child/minor for documentation, supervision, continuity of care, safety review, and record-keeping purposes.

4. Electronic communication is not monitored at all times and should not be used for emergencies, urgent safety concerns, or crisis situations. In an emergency, I understand I should call 911 or seek immediate emergency support.

5. The Katallasso Group may limit or discontinue electronic communication if it is no longer appropriate, safe, or helpful.

6. I may withdraw this consent in writing at any time, but communications already created may still be retained as part of the service record.

7. I confirm that I am the legal parent/guardian, or otherwise authorized to provide this consent.

I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g., probation, parole, supervised release, work release, etc.) I also understand that if I do revoke this consent before the expiration date, the revocation must be made in writing by me and delivered 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 also understand that I may not sign this authorization to release information, and the consequence has been explained to me.