IFH Release of Information

Release of Information
I, First Name* Last Name* , consent to allow The Institute for Healing to disclose and/or obtain information regarding my treatment with the following:
Name of Person and/or Institution
Contact information
Description of information to be disclosed:

Treatment summaryHistory/IntakeDiagnosisDates of treatment attendancePsychiatric evaluation/medication historyPsychological test resultsVerbal consultationOther (Specify)
This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date, condition, or event: blank.
I understand I have the right to refuse to sign this form and my refusal will not affect my treatment.

I may revoke my consent at any time by submitting a written request to The Institute for Healing.

My signature below confirms that I have read, understand, agree to, and consent to the information stated in the Release of Information form. I have also had the opportunity to ask questions about and understand this form.
Client Signature

Clear
Date

MonthDayYear
Date
Client Name (Printed)*
D.O.B
(For Minors Only) I declare that I am the legal guardian and/or managing conservator of First Name Last Name and grant the release of information.
This release applies to the following:

All family membersOnly the client mentioned above
Parent/Guardian Signature

Clear
Parent/Guardian Name (Printed)
Relationship to Client
Should be Empty: