2024 Release of Information

Discovery Counseling Austin

Authorization for Release of Information (ROI)

Client Name

Date of Birth

Date

*Complete a new Release for each person who need to communicate with Discovery about client's care*

I hereby request and authorize Discovery Counseling Austin and my Counselor to disclose or obtain the following information with the persons listed on this document:

What can be released or not released?

Any Information can be discussed to facilitate treatment and collaborative care.Reason for Referral (ONLY)Discharge or Treatment Summary (ONLY)Other

Please list the Provider, Family Member or Other Authorized Individual (and thier contact information below) to give us permission to share information with them about your care at Discovery Counseling Austin:

NAME*

Relationship to Client

Parent, doctor, psychiatrist, etc.

PHONE*

FAX

EMAIL

example@example.com

ADDRESS

I give permission to communicate with the above person/ facility by phone or e-mail.

Type your initials above

The Doctrine of Informed Consent has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information.

Type your initials

I also understand that HIV- related information about me, STD-related information about me, and TB-related information about e is protected by State law and cannot be disclosed unless the disclosure is authorized by State law.

Type your initials

I understand that I may revoke this consent, in writing, at any time except to the extent that action has been taken in reliance on it and that this release will be in effect for the period necessary to complete all transactions on accounts related to services provided to me.

Type your initials

I hereby acknowledge that this consent is truly voluntary.

If you wish to discuss revoking this authorization or refuse to sign this form, you can ask for assistance from your provider who can go over this information in more detail:

Client Printed Name*

Client Signature (Or Guardian if minor client)*

Guardian Printed Name (if minor client)

Date*

Date

www.discoverysounselingaustin.com

Phone: 512-607-9360 Fax 877-775-9422