Release of Information

I,   First Name*   Last Name*   , D.O.B   Date*   , authorize Vanda Counseling to:
Disclose to:*      *
Obtain from:*      *
Exchange with:*      *
  Phone:   Area Code*   Phone Number*   Fax:   Area Code*   Phone Number*

Name

First NameLast Name

Therapist you’re scheduled with*

First NameLast Name

The following information:

Other

I understand that all information about me is private. It cannot be shared with anyone without my permission unless the law says it can. I understand that I may refuse to give my permission to share this information. If I refuse, I may not receive the services I am requesting.

I UNDERSTAND THAT I MAY REVOKE THIS CONSENT AT ANY TIME BY EXPRESS WRITTEN NOTICE TO VANDA COUNSELING AND PSYCHOLOGICAL SERVICES EXCEPT TO THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON IT OR INFORMATION HAS BEEN RECEIVED AS A RESULT OF IT.

This form will expire automatically:

12 MonthsUpon receipt/ submission of requested data

Purpose for disclosure:

I understand that this information will be given only to people who need it to do their jobs. The information will be used only for the reason stated above.

Client Signature: Signature* Date: Date*
Signature of Legal Representative: Signature* Date: Date*

Release of Information Consent Form