Authorization of Release of Mental Health Record
Client's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I authorize CrossPoint Clinical Services, Inc. to:
*
Send
Receive
the following:
*
To
From
Authorized Contact
*
First Name
Last Name
Authorized Contact's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Contact's Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
A SEPARATE AUTHORIZATION IS REQUIRED FOR PSYCHOTHERAPY NOTES
Academic Testing Results
Behavior Programs
Progress Reports
Intelligence Testing Results
Medical Reports
Personality Profiles
Psychological Reports
Psychological Testing Results
Service Plans
Summary Reports
Vocational testing results
Entire records, except Progress Notes
Psychotherapy Notes
Other
The above information will be used for the following purposes:
Planning appropriate treatment or program
Continuing appropriate treatment or program
Determining eligibility for benefits or program
Case Review
Updating Files
Other
Your Relationship to the client:
Self
Child/Legal Guardian
Legal Representative
Other
Date of Digital Signature
-
Month
-
Day
Year
Date
Client's/Legal Guardian's Signature
*
Clear
Submit
Should be Empty: