Release of Information

TREEHOUSE PSYCHOLOGY, PLLC
Patient/Parent Permission to Obtain/Release Information
Patient Name*
Date of Birth*

MonthDayYear
Date
Parent/Guardian Name (if patient is minor)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
* I, the undersigned, hereby request and authorize Treehouse Psychology, PLLC:
Check all that apply:

To Release toTo Exchange withTo Obtain From
Sharing Provider Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #*
Fax #*
The following information*

Psychological/Neuropsychological EvaluatioDiagnostic AssessmentPhone ConsultationMedical Records/Chart NotesSummary of Therapy
* I understand that, except for research-related treatment, Treehouse Psychology, PLLC will not condition my treatment, payment enrollment, or eligibility for benefits on my signing of this authorization. I do not authorize further release to any third party. I understand that once released as specified in this authorization, the facility, their employees and my physician(s) cannot prevent the re-disclosure of that information. I hereby release each of them from any and all liability arising directly or indirectly by this consent and any re-disclosure of that information.
Date*

MonthDayYear
Date
Signature*

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TREEHOUSE PSYCHOLOGY, PLLC