REQUEST TO RELEASE/EXCHANGE RECORDS AND INFORMATION

Debra Caplowe, LCSW

REQUEST TO RELEASE/EXCHANGE RECORDS AND INFORMATION
I hereby authorize (Full Name)
and/or (Full Name)
Street Address
City, State, Zip code
to release/exchange information from the records of:
Full Name
Street Address
City, State, Zip code
for the purpose(s) of further mental health/psychological evaluation or treatment, or other purposes stated here:
The following information from the record is requested:

Intake and Discharge Summaries Psychological Evaluations Progress Notes/Closing Summary Medical Records Developmental/Social History Educational Records Other
This authorization is signed with the understanding that the information will not be passed on to anyone else, or be used for any other purpose other than specified.
Authorization expires (Maximum of one year from date signed)

Month Day Year
Date
Date Signed

Month Day Year
Date
I understand that this authorization may be revoked at any time to the extent that action based on this consent has been taken.
Patient Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Witness Signature

Clear
Date

Month Day Year
Date
DEBRA CAPLOWE, LCSW | Licensed Clinical Social Worker

131 W. Great Falls Street, Suite 101, Falls Church VA 22046 | 703-795-4226
Should be Empty:

Debra Caplowe, LCSW