Choosing Change

Authorization to Release/Receive Information

I give Choosing Change Counseling LLC, consent to share information about my treatment history, as well as recieve information that could be supportive to my treatment with/from the person and/or company below, :

Name of Client

Name of Therapist(s) at Choosing Change Counseling

Name of Individual from Whom Information Will Be Released or Requested

Name of Company from Whom Information Will Be Released or Requested

Nature of Relationship with Whom Information Will Be Released or Requested

Email for Whom Information Will Be Released or Requested

example@example.com

Phone for Whom Information Will Be Released or Requested

Format: (000) 000-0000.

Address for Whom Information Will Be Released or Requested

Please INITIAL underneath the aspects of your treatment that you consent to sharing and/or receiving with/from the above individual and/or company.

Prognosis

Treatment Summary

Dates of Attendance

Relapse Occurred

Other

If other, please be specific to what other information you would like to be released or received.

Date

Print Name

Your signature below confirms your consent to the above information.

Name of minor child under 14 years of age, if applicable.