Authorization for Release of Information (ROI)

1
Client Full Legal Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Client Phone Number* This field is required.
Please enter a valid phone number.
4
Client Email Address* This field is required.
example@example.com
5
Releasing Provider Name/Practice* This field is required.
Shanae Farquharson, LMFT/FaithWorks Therapy
6
Releasing Provider Email Address* This field is required.
sfarquharson@faithworkstherapy.com
7
Receiving Provider, Person Name or Client Name (Self)* This field is required.
8
Receiving Practice / Agency/ Relationship * This field is required.
If records are being released directly to the client, enter “Self.”
9
Receiving Provider/ Person Phone Number* This field is required.
Type your number if info is sent to you
10
Receiving Provider/Person Email Address* This field is required.
Type your email if you would like info released to you
11
This authorization allows two-way communication between the providers listed above.
12
Methods of Authorized Communication (Select at least 1)* This field is required.
Verbal communication (phone or in-person)
Written communication (email, letters)
Electronic records exchange (secure platforms)
13
Information Authorized for Release* This field is required.
Intake information
Diagnosis & Treatment goals
Treatment Summary Letter Request
Coordination of Care/Consult with another Health provider
Talk with Partner/Family member
Other
14
Purpose of Disclosure* This field is required.
Continuity of Care
Coordination of Treatment
VA Benefits/Disability Claim
Personal Use
Legal Matter
School/Work Accommodation
Other
15
I understand that certain information related to substance use treatment, HIV/AIDS status, and other specially protected health information may be subject to additional protections under federal and state law and may not be disclosed without specific authorization.* This field is required.I understand and Agree
I understand and agree
16
Expiration of Authorization* This field is required.
Please Select
Please Select
90 Days
1 Year
Upon Completion of Requested Disclosure
Other
17
If you selected 'On a specific date,' please specify the date:
Date
Month
Day
Year
18
Type of Request* This field is required.
Disability Paperwork
FMLA
Work Accomodation
Emotional Support Documentation
Records Request
Other
19
Other, Explained
20
Approximate dates of sessions attended* This field is required.Dates provided will be cross-verified with the therapist’s clinical records.
Include Intake Date
21
Date symptoms began worsening* This field is required.This could be before or after sessions began
Date
Month
Day
Year
22
Last session attended* This field is required.
Date
Month
Day
Year
23
Symptom Information* This field is required.Please describe the symptoms you currently or were experiencing at time of service
E.g. Anxiety/panic, Depression, PTSD symptoms, Sleep issues, Concentration difficulties, Emotional dysregulation, Fatigue/burnout, Flashbacks, Social withdrawal, etc.
24
Functional Impact* This field is required.How do your symptoms negatively impact your daily functioning? If none, Type "None"
E.g., Personal care, Household tasks, Sleep, Parenting, Relationships, Motivation, Memory/focus, Leaving the home, Emotional regulation etc. If not affect, Type "N/A"
25
Work Impact/limitations* This field is required.What job duties are difficult to complete due to your symptoms? If none, Type "None"
Include: Job title, Description of daily job tasks, Physical demands, Cognitive demands, Customer-facing duties, Attendance issues, NA,Specific work limitations
26
If requesting time away from work or accommodations, what date do you anticipate returning to regular work duties?
Date
Month
Day
Year
27
Supporting Information* This field is required.What would you like your provider to understand about your current struggles ? What specific accommodations or support are you requesting ? If none, Type "None"
E.g. FMLA leave, short-term disability, remote work, reduced hours, flexible scheduling, additional breaks, modified duties, or workplace accommodations.
28
Supporting Documents Upload (Optional)Upload any documents you would like your therapist to review or include with this authorization request.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
E.g. VA paperwork, disability/FMLA forms, prior records, referral forms, accommodation requests, insurance documents, evaluations, discharge paperwork, or other documents related to your request
Cancelof
29
Client Consent* This field is required.I understand that I may revoke this authorization at any time by providing written notice. Revocation will not apply to information already shared based on this authorization. The information provided may be used as part of the clinical assessment and documentation process for requested forms, letters, disability paperwork, accommodations, leave requests, or related records. Submission of this form does not guarantee approval or completion of requested documentation.
30
Date Signed* This field is required.
Date
Month
Day
Year
31
DateTime
Should be Empty: