KBR Counseling and Services, PLLC

KBR Counseling and Services, PLLC

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Date
Information released to(check all that apply).*

LyraReferring agencyInsurance CompanyMCOPhysicianPsychiatristEmergency ContactDepartment of Community Correction (PO)Defense AttorneyDepartment of Motor VehicleDivision of MH/DD/SASOther
Please list the name of the Insurance Company, emergency contact and/or agency, etc. * .

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Please list the name of the Insurance Company, emergency contact and/or agency, etc. .

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Information released from/to:

KBR Counseling and Service, PLLC/KaiRashia Boyce Rasberry

2519 Airport Blvd NW Ste C

Wilson, NC 27896

252-265-3104 (P) 252-296-9060 (F)
I authorize KBR Counseling and Services, PLLC to have continuous dialogue between the personnel of KBR Counseling and Services, PLLC and the individual or group identified above. The individual or group identified above is also hereby authorized to release or share information with KBR Counseling and Services, PLLC. I understand that this release is valid for one year unless revoked in writing before then.
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Description of information to be released/Reason for Disclosure (if not check, then assumed refused)

Continuity of Care/treatment coordinationDiagnosis and Treatment plan for Billing PurposesComprehensive Clinical AssessmentSummary of PrognosisSubstance Use Related Diagnosis and TreatmentRestoration of Driver's
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