Authorization for Release of Information

Authorization for Release of Information

CONFIDENTIAL

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Date

DateHourMinutesAM/PM Option

Client's Name

First NameMiddle NameLast Name

Client's Birth Date

Client's Phone Number

Format: 000-000-0000.

Client's Address

Street Address

Street Address Line 2

CityState

Zip Code

Current Therapist Name

Is Client under age 14? All legal guardians must sign a release form.

I authorize the release of confidential client information to the person or organization listed below. I understand that I may revoke this authorization at any time by submitting written notice. Please provide, in the space below, the contact information for the individual or organization with whom information is to be shared.

Name of the person your therapist can share info with:

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Format: 000-000-0000.

Fax Number

Format: 000-000-0000.

Email

example@example.com

If applicable, I give full authorization to release all previous Peacemaker therapist's progress notes to my new therapist:

If yes, indicate new therapist name:

Client Signature

Sign with your mouse, stylus, or finger

Parent/Guardian Name if child under age 14

Parent/Guardian Signature if child is under age 14

Sign with your mouse, stylus, or finger

Parent/Guardian Name if child under age 14

Parent/Guardian Signature if child is under age 14

Sign with your mouse, stylus, or finger