Clone of New Client Paperwork

Coordination of Care
Is there a medical professional you would like SLC and your therapist to coordinate care with?

YesNo
This form helps us coordinate your care by allowing us to communicate with your medical providers. You choose who we can speak with, what information you’d like us to share, and how far back the release should go.

*If you need to authorize someone who isn’t a medical provider, please use our Release of Information form instead.*
I authorize my therapist/SLC to:*
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Your SLC Therapist*
Your SLC Therapist's Email
example@example.com
Approved Provider*
Relationship to You*
Their Phone Number*
Please enter a valid phone number.
Their Fax Number*
Please enter a valid phone number.
Office/Group Name
Their Office Email
example@example.com
Their Address*

Street Address

Street Address Line 2

CityState

Zip Code
Purpose of Disclosure*

Coordination of CareContinuity of CareOngoing TreatmentDisability DeterminationTreatment PlanningAttendance
Information to be Disclosed*

DiagnosisTreatment PlanProgress NotesPsychological Assessment ReportComplete RecordsBiopsychosocial Assessment
Which dates should we include?*

All dates from my time at SLC ♾️Specific date range ↳
Start Date of Authorization*

MonthDayYear
Pick the first date of the records you want us to share.
End Date of Authorization

MonthDayYear
Leave blank for ongoing release.
Your relationship to the client:*

Parent/Legal GuardianSelf
Consent*

By checking this box and typing your name below, you acknowledge and agree that this action constitutes your legal signature under Michigan law and is as valid and enforceable as a handwritten or electronic signature.
Your Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Re-Disclosure

I understand that this information may be protected by the Title 42 (Cod of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I understand that my Protected Health Information (PHI) that is used or disclosed under this authorization may be subject to re-disclosure by the recipient, and the privacy of my PHI may no longer be protected under these guidelines if they are not a health care provider covered by state or federal rules. The federak rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

Revocation of Authorization

I understand that this authorization is voluntary and may be revoked in writing at any time, except to the extent Silver Linings Counseling has already taken action upon it. I understand that if I revoke this authorization, I must do so in writing. Silver Linings Counseling will not condition treatment or payment based on this authorization or revocation of the authorization unless otherwise allowed by law.
Should be Empty:

Coordination of Care