Authorization & Release

Authorization & Release

Orchard Human Services, Inc.
I authorize the reciprocal sharing of information about my care [including treatment, diagnosis, and financial issues] between Orchard Human Services, Inc. staff and representatives, including Dr. Darleen Claire Wodzenski, LPC, NCC, and another person(s) that I designate on this form [whether another provider, school official, family member, significant other, etc.] If the client is a minor or is in the care of a legal guardian, then the parent or guardian shall sign on behalf of the client.
Name of Client

First NameLast Name
Date of Birth of Client
My relationship to the client
Please select one of the above options to explain your relationship to the client.
Name of Person I Authorize To Discuss Case (including diagnosis, treatment, clinical findings, and finances)

TitleFirst NameLast NameSuffix
Email Address of Person I Authorize To Discuss Case
example@example.com
Phone Number Of Person I Authorize To Discuss Case
Please enter a valid phone number.
Other Contact Information Of Person I Authorize To Discuss Case
I authorize Orchard Human Services, Inc. staff and representatives and the above-named individual I designated above to share information about my care (including diagnosis, treatment, clinical findings, and finances) to support continuity of care. The person I designated serves in the following role:
Please select the role of the person you designated above to reciprocally share information with Orchard Human Services, Inc. staff and representatives.
If you selected OTHER above, please indicate the role or relationship of this individual to the client role or relationship to client such as "Aunt" or "Social Worker"
Signature

Clear
Please type name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: