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
Client's Birth Date

MonthDayYear
Client's Phone Number
Format: 000-000-0000.
Client's Address

Street Address

Street Address Line 2

CityState

Zip Code
Current Therapist Name
YesNo
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
YesNo
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
Should be Empty: