RELEASE
Name of client
*
Date of birth
*
I authorize Western Reserve Counseling, LLC to release verbal and written information regarding (please check all that apply):
*
Diagnostic Assessments and Updates
Progress notes
Consultation Information shared in a staffing
Discharge Summary
Treatment Plans
Recommendations
Health History
Treatment Progress and Attendance
Name of person/organization to be release to and/or from:
*
Type the name of the person to whom you are giving permission for your information to go to
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: