Limited Release of Information Form

READ FIRST: Parent Child Therapeutic Serices must keep information about you private. The only time your personal information should be shared is when you want us to for specific services or if we are compelled by law or court order.

You never have to agree to share your information. We will still help you and provide our services.
If you do want Parent Child Therapeutic Services to share some information about you, use this form to give instructions about what you do and don’t want shared, and with whom you want it shared.
Before you sign this, someone at Parent Child Therapeutic Services will discuss your goals/needs, your choices for how to meet those, and the pros and cons of having us share the information for you.
You can change your mind about what you want shared at any time, and we will update this form to reflect your decision.

I request the following 6-instructions be followed for Parent Child Therapeutic Services at Impact NW to share my information with others as indicated below:

[Step #7 is only for extending my authorization]

My IMPACT NW Counselor's First Name is:*

1) I want this information about me shared: (*Be as specific as possible. A few examples include: my name, dates Igot help, documents about me)*

2) I want the information shared with this person or agency: *( Be specific)*

3) I want the information shared:*

	Yes OK to share by this method	No, Not Ok to share by this method
In person
Fax
Email
Email
Phone
Mail
Text
Other method

4) Sharing this information helps me because:

5) I know that once the information is shared by Parent Child Therapeutic Services (PCTS):

Others will know that I have worked with PCTS,
Others might try to get more information about me from PCTS, and
The person/agency receiving my information might share it without asking me first.

6) I want PCTS to stop sharing the information above on the following date, and I know that I can change my mind and tell PCTS to stop sharing sooner than this date: (*up to 6 months from today's date)*

MonthDayYear

Parent or Guardian Signing this Form: (First and Last Name)*

Signature*

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