Release Form - Edwards Psych

Authorization for the Release and Exchange of Information
Client Name

First NameLast Name
I authorize Edwards Psychological Associates to release and exchange information about my case with the following parties:

* If utilizing school support resources, please include counselor and/or other relevant personnel.
Name
Relationship
Phone Number
Name
Relationship
Phone Number
Information to be Released or Exchanged (check all that apply):

All Relevant Clinical InformationIntake and HistoryDiagnosis and Treatment PlanTreatment ProgressBilling & PaymentAttendance OnlyTreatment SummaryOther
This release shall be valid until termination of treatment or until withdrawn in writing during the course of treatment.
Client name
Signature

Clear
Date

MonthDayYear
Date
Client name
* Partner's name for couples & families
Signature

Clear
Date

MonthDayYear
Date
FOR MINORS ONLY:
Parent/Guardian name
Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: