Release of Information Form

FAMILY CONNECTIONS

Authorization for Recording
5891 Cedar Lake Road South, St. Louis Park, MN 55416

ph. 952-544-0964

fax 952-544-6405

www.familyconnectionsmn.com

RELEASE OF INFORMATION FORM
Name*

First NameLast Name
If Client is a child, please provide child's name.

First NameLast Name
Date

MonthDayYear
Date
Therapist's name:*
Email of the therapist*
example@example.com
Name of Authorized Individual to exchange or release information with*

First NameLast Name
I hereby authorize my therapist (listed above) to exchange/release information and/or documents with the Authorized Individual named above for the purposes of providing appropriate mental health services. The specific information and/or documents include:
Type a question*

Admission/Discharge SummaryAssessment/EvaluationProgress/Consultation ReportsPsychological Testing/ReportsMedical/Psychiatric RecordsChemical Health AssessmentFamily History InformationCourt RecordsLaw Enforcement ReportsStaffing SummarySchool InformationSocial History
I have fully read and understand this Release of Information. I understand my records are protected by Federal Law (42 CFR Part 2) and cannot be disclosed without my permission as indicated by my signature below, unless otherwise provided in the Federal Regulations. I also understand I may revoke this release at any time prior to the information being exchanged. This Release of Information will automatically expire 365 days after date of signature.

Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.

By e-signing you acknowledge your agreement with the information in this document.
Client Signature (or parent/guardian)*

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Clinician Signature

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Date of Clinician Signature

MonthDayYear
Date
Should be Empty:

FAMILY CONNECTIONS

RELEASE OF INFORMATION FORM