I hereby authorize Danya (River) Epstein Gass to request and/or release information with the above stated Care Provider regarding mental health and other types of services being provided; Client’s social, physiological and emotional functioning; and any medical issues pertaining to Client's overall wellness. This exchange of information is for the purpose of treatment planning and evaluation, and the comprehensive coordination of care.
I understand that Federal Regulations may protect my medical records; I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.