I authorize Anchored in Hope Counseling Services LLC to release or receive information including medical records, treatment plans/summary, and diagnosis to the following family/ friends for reasons such as discussing concerns, contributing to treatment goals, and any other opportunities to support treatment:

I authorize Anchored in Hope Counseling Services LLC to release or receive information including medical records, treatment plans/summary, and diagnosis to the following providers for reasons such as planning appropriate treatment, updating files, and any other opportunities to provide continuity of care:

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.