General ROI (ALCS)

Authorization for Release of Information
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Email
example@example.com
I authorize the therapist below and Abundant Life Counseling Services, P.A.
   *

To: (check all that apply)
Disclose information to    Receive Information from*
The following Second Party:
Second Party Name
Second Party Email Address*
example@example.com
Second Party Phone Number*

Area CodePhone Number
Second Party Fax Number

Area CodePhone Number
The type of information to be shared is: (check all that apply):*

Invoicing/Receipts for ServicesCurrent Treatment UpdateTreatment Plan or SummaryConsultationDiagnosisDischarge/Transfer SummaryEvaluation or AssessmentProgress NotesPsychological Testing InformationPsychiatric EvaluationSchool RecordMental Health HistoryEntire RecordOther Specific Information (please specify)
Please elaborate if your above answer was "other."
The purpose of disclosure is:*

BillingContinuity of careCase ManagementOther (if other, please specify)
Please elaborate if your answer above was "other."
I understand that I am under no obligation to authorize disclosure of information requested. In addition, I understand that this authorization will be valid until termination of care from Abundant Life Counseling Services, P.A. unless revoked by written notice.
Name of Client (or parent/guardian if client is a minor)*

First NameLast Name
Client Signature (or parent/guardian if client is a minor)*

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Date Signed*

MonthDayYear
Date
Should be Empty:

Authorization for Release of Information