Authorization For Disclosure of Mental Health Treatment Information(Client under 12 years of age)

Authorization For Disclosure of Mental Health Treatment Information(Client under 12 years of age)
Name of Parent or Legal Guardian of Client
Name of Client receiving services

Client birthdate (mm/dd/yyy)
Client's Address (Street, City, State, ZipCode)
I the parent or legal guardian authorize The Rock Counseling Group to disclose and obtain from the individual or organization listed below:
Name of Person or organization information is being obtained or released
Phone Number of Contact Person
Address of Persons or organization:
Street Address
City
State
Zip code
Type a question

Demographic InformationAppointment Times and AttendancePayments, Receipts, and InvoicesInitial AssessmentPsychosocial AssessmentDiagnosis OnlyPsychotherapy NotesTreatment Progress SummaryTreatment PlansPresence/Participation in TreatmentContinuing Care PlanOther
Purpose: This information may be used or disclosed in connection with mental health treatment, treatment coordination, or payment for services rendered. If the purpose is other than as specified, please provide additional information:
Other Reason:
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time by sending a written notification to The Rock Counseling Group at 201 West Springfield Ave, Suite 1201 Champaign, IL 61820 attention: medical records. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the

Expiration: Unless sooner revoked, this authorization expires 365 days from the date completed or as otherwise indicated:
Expiration of Release Date preferred

MonthDayYear
Date
Forms of Disclosure: Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.
Signature of client over 12 years or legal guardian

Clear
Signature of Parent or Guardian if client under 12 Years

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty: