3300 Yonge Street, Suite 303, Toronto, Ontario, M4N 2L6 Phone: 416-953-9820

______________________________________________________________________________

AUTHORIZATION TO RELEASE INFORMATION

To: ________________________________________

Re: _______________________________________

I, ___________________________________ and _________________________ authorize the

office of Ilana Tamari to discuss with, provide information and receive information, including records,

assessments, documents and other material from the above agency or person about me and or my

child(ren). I understand that the information collected may be disclosed for the purposes of a

custody and access assessment, parenting coordination, mediation or arbitration.

Name and date of birth of children:

1. ________________________________________

2. ________________________________________

3. ________________________________________

I understand this authorization is valid for twelve months after the date signed.

______________________________ ___________________________

Please Print Name and Please Sign Please Print Name and Please Sign Dated: Dated:

Yours truly,

Mediator – Arbitrator - Parenting Coordinator - Custody Evaluatorwww.ilanatamari.com

______________________________________________________________________AUTHORIZATION TO RLEASE INFORMATION