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Minor- Authorization and Consent for Release and Disclosure of Confidential Information
Hi there, please fill out and submit this form only if you have been asked to do so by your assigned therapist. Thank you so much!
6
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1
Parent or guardian information
*
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Full Name
Date of birth
Full address including zip code
Phone number
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2
Minor's information
*
This field is required.
Full Name
Date of birth
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3
The minor's therapist:
*
This field is required.
Veronica Vaiti
Amir Levine
Claire Corbetta
Eliana Panora
Rachel Kimelman
Emily Shapiro
Amanda Veras
Cayley Kasten
Melissa Dominguez
Maria Del Rosario
Alyssa Kushner
Anginese Philips
Nancy Gershman
Amanda Sacks
Glendenise McPherson
Bailey Brown
Nitin Kini
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4
I authorize and give my consent to the above-named practitioner and/or the administrative and clinical staff of the above named practitioner to discuss all aspects of my child's medical, psychotherapy and/or psychiatric treatment without restriction or qualification with:
*
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Name of collateral individual
Organization collateral individual is affiliated with
Phone number of collateral individual
Fax number of collateral individual
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5
Today's date
*
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Date
Year
Month
Day
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6
Signature
*
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