Consent to Release Information

Consent to Release Information

Please complete the consent form using the exact wording of the extracted prompts and provide the required signature and date.
Client and Contact Information
Client Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where do you want the records released to? Agency/Contact Name:
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone/Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Authorization Type
Check all that apply:
Records for limited verbal communication
Documents to be mailed/faxed to the agency listed above: ABA Records, Mental Health Records, Progress Summary.
Purpose of Release and Compliance
Purpose of Release:

Other
Signature and Relationship
Client (if adult)/Legal Guardian (if minor) Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Client
Should be Empty: