Authorization for Release of Information

Authorization for Release of Information

CONFIDENTIAL
Para completar este formulario en español, presione aqui.
Date

MonthDayYear
DateHourMinutesAM/PM Option
Client's Name

First NameMiddle NameLast Name
Current Therapist Name
Is Client under age 14? All legal guardians must sign a release form.*

YesNo
Client's Address

Street Address

Street Address Line 2

CityState

Zip Code
Client's Phone Number
Client's Birth Date

MonthDayYear
I give full authorization to release confidential client information to the following person or organization:*
Please indicate full name of person or organization.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Fax Number
Email
example@example.com
If applicable, I give full authorization to release all previous Peacemaker therapist's progress notes to my new therapist:

YesNo
If yes, indicate new therapist name:
Client Signature

Clear
Sign with your mouse, stylus, or finger
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Clear
Sign with your mouse, stylus, or finger
Parent/Guardian Name if child under age 14
Parent/Guardian Signature if child is under age 14

Clear
Sign with your mouse, stylus, or finger
Should be Empty: