Consent to Release of Information

Consent to Release of Information
Associates In Psychotherapy
Deerfield • Evanston • Chicago • Barrington
(866) 220-8371
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Vanessa J. Allen, MSW, Ed.D, LCSWUdisha Bhadury, LPCTina Casey, LSWMichelle Chaban, Psy.D.Joshua Donohue, LPCSamantha Fox, Psy.D.DeeDee Goldman, LCSWErica Hornthal, LCPCAmy Kingan, Psy.D.Erin Lipin, LCSWAnne Marie McGuire, LCSWJen Meyer, LCPCSamantha Nusinow-Kolko, LSWCarey Rand, LCSWMegan Ray, LCPCAlicia Rogers, LCSWCatherine Santo, LCSWKimi Simms, LCSWCindy Templer, Psy.D.Allison Yambor, LCSW
I, First Name* Last Name*, authorize Associates In Psychotherapy:
to release and/or obtain the following information:*

Medical ReportsTesting ReportsTreatment PlansVerbal Communication that is relevant to psychological treatmentPsychotherapy Notes (requires separate authorization)Entire Record, except progress notesOther
Describe Other:
This information should only be released to or obtained from:*
Purpose for disclosure:*

Planning or determining appropriate treatmentContinuing appropriate treatmentDetermining eligibility for benefits or programProfessional ConsultationCouples & Family CounselingOther
I agree I don't agree* that my therapist can communicate with others in an electronic format (i.e. emails/texts). I understand he/she/they cannot guarantee confidentiality and security of these communications.
I understand I may revoke this authorization at any time by giving written notice, except to the extent this request has already been fulfilled. Additionally, my revocation will not be effective if this authorization was obtained as a condition of receiving insurance coverage and the insurer has a legal right to contest a claim. Otherwise, this consent will be considered valid for one year from the date written below. This consent will expire on Date .

I understand my therapist generally may not condition psychological services upon my signing this authorization unless these services are provided to me for the purpose of creating health information for a third party.

I understand I have the right to inspect the disclosed mental health information at any time. I understand Illinois law prohibits redisclosure of any information disclosed to the recipient pursuant to this authorization unless this authorization specifically authorizes such redisclosure.
Name*

First NameLast Name
Signature of Client*

Clear
Date*

MonthDayYear
Date
Parent or Guardian (both signatures required if client is between 12-17 years old. If under 12 years old, parent/guardian only)
Name of Parent or Guardian

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Name of Parent or Guardian

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: