Authorization for Release/Exchange of Information
By signing this form you give your counselor written permission to communicate with other individual providers regarding your treatment, if needed.
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Release of information from
Name
to Another Person or Party.
I authorize my Counselor to release/exchange the following information to:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information to be released (Please Check):
Screening Information
Behavioral and Psychological Reports
Treatment Plan
Counseling Notes
Coordination of Care
Intake Form and History
Other: _____________________________
Name of Patient, Client or Authorized Person
Signature of Patient, Client or Authorized person
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: