CONSENT & AUTHORIZATION TO RELEASE INFORMATION

CONSENT & AUTHORIZATION TO RELEASE INFORMATION

If there are other parties that may assist in your therapy or provide medical records, and you believe it would be helpful for your therapist or psychiatric provider to contact them regarding your treatment, please read carefully and complete this document. The following is an authorization for the stated parties to consult with one another regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the necessary information and your signature with today’s date as indicated below.
I,Client Name hereby authorize Therapist or Psychiatrist Name and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist's diagnosis:
Party One
Party One Email (optional)
Party One Phone Number
Party One Fax Number
Party Two
Party Two Email (optional)
Party Two Phone Number
Party Two Fax Number
Party Three
Party Three Email (optional)
Party Three Phone Number
Party Three Fax Number
Party Four
Party Four Email (optional)
Party Four Phone Number
Party Four Fax Number
Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form.

Please indicate your preference regarding the information to be shared:
The parties stated above may discuss my medical and/or mental health information without limitations.

YesNo
I would prefer to limit the information shared between the parties stated above.

YesNo
The limitations are as follows:
Additionally, the above named parties, therapist & person(s) or entity (entities) designated under (1) or (2), agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these parties is considered a breach of confidentiality.

Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by the above named therapist at 2876 Johnson Ferry Rd., #150, Marietta, GA 30062 or 1041 Cambridge Square, Suite A, Alpharetta, GA 30009 or email to info@alanbehrman.com from clients documented email address to be effective.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Parent or Guardian Name (if patient is a minor)

First NameLast Name
Parent or Guardian's Signature (if patient is a minor)

Clear
Should be Empty: