Authorization of Information Exchange for Lori Conroy LMFT

Authorization to Exchange Information for Sylvan Streightiff, AMFT

(Supervised by Lori Conroy, LMFT, CA License #47658)
Dear Client:

This form has been created to protect your rights to confidentiality. It specifies what Designated Information about you may be recevied from, disclosed to, or exchanged with an Authorized Third Party, and the Purpose of that information.

All blanks must be filled in, then sign the form and click on Submit.

By signing this form below you agree to the following:

I authorize Sylvan Streightiff, AMFT ("the Therapist") to disclose, receive or exchange the Designated Information with the Authorized Third Party for the Purpose specified below.

This Authorization expires one year from the date shown. However, I understand that I have the right to cancel or modify this Authorization at any time in writing.

I understand that I have a right to receive a copy of this Authorization.

The Therapast will not release to any other 3rd party any of the Desigated Information without prior written permission.
Your Full Legal Name*
Your Email Address*
example@example.com
Authorized Third Party: Full Name Phone and Email*
Please chose one of the following Disclosure options*

I authorize the Therapist to disclose (send) the Designated Information to the Authorized Third PartyI authorize the Therapist to Receive the Designated Information from the Authorized Third PartyI authorize the Therapist to exchange (send and receive) the Designated Information with the Authorized Third Party
Designated Information (including any limits)*
Enter "Unlimited' if there are no restraints on the Information to be exchanged.:
Purpose*
For example: "To aid in my therapy with Daniel"
Today's Date*

MonthDayYear
Date
Your Signature*

Clear
Use your mouse or touch screen to sign
Should be Empty:

Authorization to Exchange Information for Sylvan Streightiff, AMFT