ROI-General

A Better Way Counseling Service, LLC

General Release of Information
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Current Date *

Month Day Year
Date
I authorize the following information to be exchanged between the below party and A Better Way Counseling Service:
Please check all that apply *

Intake Information Progress Reports Discharge Summary Police Reports Court Documents Phone Contact Payment Assessment Results
1. Named Party You Are Releasing the Above Information To *

First Name Last Name
1. Named Party you are authorizing A Better Way Counseling to communicate with: *
Organization

Attorney Current partner Any adult children who are biological to or have lived with the participant The victim's community and legal advocates Mental health agencies Department of Children, Youth, and Families (DCYF) Individual therapists Substance use treatment programs
Email
example@example.com
Named Party Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Named Party Phone Number
Named Party Fax Number
2. Domestic Violence Treatment Program Manager and Washington State Department of Social and Health Services with Community Services Division
Signature of Client *

Clear
This release is valid for one year after completion or termination of designated treatment. A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or other substantial action has been taken in reliance on the authorization. A patient may not maintain an action against the health care provider for disclosures made in good-faith reliance on an authorization if the health care provider had no actual notice of the revocation of the authorization. In compliance with WAC 110-60A we will have to consider if the release is required for continuing your treatment program. If a required release is revoked we may terminate you from our program. This release covers information being released to Washington State Department of Social and Health Services.
Should be Empty:

A Better Way Counseling Service, LLC