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
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]