Counseling Release Of Information Form Template

Insert name of person or title of person or organization description of information to be disclosed patient client should initial each item to be disclosed.

Counseling release of information form template. The information that is used. The following information. You may come in to the counseling center and fill one out or you may print it from this website fill it out at home and bring it to the counseling center or fax the completed form to us at 410 516 4286. Release of information form template mental health psychotherapy release of information form this template can be used to coordinate the release of confidential information during a client s transition of care or other cicrumstances where private records need to be shared.

You do not need this form for the first session unless you need me to coordinate care with a doctor other than your primary care physician. I authorize the release of my confidential protected health information as described in my directions above. If you would like someone to be able to communicate with the counseling center about your treatment you must fill out a pdf document. Authorization for release of information.

Client psychotherapy intake form limits of confidentiality therapy cancellation policy if you would like me to coordinate care with another provider for example your psychiatrist primary care physician etc complete this form to authorize release of psychotherapy information. I understand that this authorization is voluntary that the information to be disclosed is protected by law and the use disclosure is to be made to conform to my directions.