Release of Information

Release of Confidential Mental Health Information
Client Name
Social Security
DOB
Address

Address

Street Address Line 2

CityState

Zip
Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals offamily members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax
Please enter a valid phone number.
Add Another Person? 2
Name 2

First NameLast Name
Relationship 2
Phone Number 2
Please enter a valid phone number.
Email 2
example@example.com
Fax 2
Please enter a valid phone number.
Add Another Person? 3
Name 3

First NameLast Name
Relationship 3
Phone Number 3
Please enter a valid phone number.
Email 3
example@example.com
Fax 3
Please enter a valid phone number.
Add Another Person? 4
Name

First NameLast Name
Relationship 4
Phone Number 4
Please enter a valid phone number.
Email 4
example@example.com
Fax 4
Please enter a valid phone number.
Add Another Person? 5
Name 5

First NameLast Name
Relationship 5
Phone Number 5
Please enter a valid phone number.
Email 5
example@example.com
Fax 5
Please enter a valid phone number.
Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination. Signature | hereby authorize the use or disclosure of my personal mental health information as described above If patient is under the age of 18 a parent or guardian may sign that consent to disclose information
Patient Name
Signature

Clear
Date

MonthDayYear
Date
Signature Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.
Jordan West Family Counseling Version 07-2024
Should be Empty: