Name
Date of Birth
I Hereby Authorize
To Release to
The Following Information: (Information to be disclosed)
Medical Educational Psychiatric Vocational Psychological Social Other
If you selected Other, please explain:
Purpose of Disclosure
I understand that the nature of this authorization is to release information and that I can revoke this consent at any time by written communication. The revocation of this consent will be effective the date it is received by the clinician.
I authorize this release of information until:
Client Signature: Date:
The recipient of these records is reminded that further disclosure of these records without client consent is prohibited.
Disclosure upon consent of a minor: A minor client 14 years or older receiving mental health treatment is to consent to the disclosure of his or her records in the same manner as an adult. Release of information expires after three months unless otherwise specified on this form.
**All fields must be completed in order to successfully submit this form
