AUTHORIZATION FOR RELEASE OF INFORMATION OR RECORDS

Hicks Counseling Services
Beverly Hicks, M.Ed.
NC: LCMHC, CCS, CADC
TX: LMFT, LCDC

Mailing: 9650 Strickland Rd. Suite 103-424
Raleigh, NC 27615

Office: 919.904.4257
Fax: 866.594.1848
www.hickscounseling.com

Hicks Counseling Services, PLLC.

Beverly Hicks, M.Ed.NC: LCMHC, CCS, CADCTX: LMFT, LCDC
AUTHORIZATION FOR RELEASE OF INFORMATION OR RECORDS
Client Name (please print):*
Date of Birth:*
Authorized Representative (If different from client (please print)):
Contact Phone:*
Email:
example@example.com
I hereby give permission for Beverly Hicks, M.Ed., LCMHC to disclose clinical information and/or obtain information from;

Family MemberDoctorLawyerHospitalSchoolOther
Contact Name

First NameLast Name
Phone:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Expand this to add another individual
I hereby give permission for Beverly Hicks, M.Ed., LCMHC to disclose clinical information and/or obtain information from;

Family MemberDoctorLawyerHospitalSchoolOther
Contact Name

First NameLast Name
Phone:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Expand this to add another individual
I hereby give permission for Beverly Hicks, M.Ed., LCMHC to disclose clinical information and/or obtain information from;

Family MemberDoctorLawyerHospitalSchoolOther
Contact Name

First NameLast Name
Phone:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Authorized Information for Release
I am authorizing the following information to be released (please check only the items you authorize to be released):

Scheduling and/or billing informationPhone Consultation (preferred)Attendance RecordDiagnosis and assessmentProgress report on treatmentTreatment recommendationsOther
I may revoke this consent at any time with a written request. This authorization will expire one year after the date of this document.
Signature Client or Authorized Representative (parent of guardian):

Clear
Date:

MonthDayYear
Date
Should be Empty: