Mental Health Release

Thank you for taking the time to complete this standard authorization for disclosure of mental health treatment information, which will allow me to connect with your provider in an effort to provide the best treatment possible.

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Contact Email

Client Name

First

Last

Date of Birth

Name of Mental Health Counseling Organization

Please indicate the business name of the provider intended to disclose to and/or obtain information.

Name of Individual Provider

Please indicate the person (doctor, psychiatrist, psychologist, licensed mental health profession) name of the provider intended to disclose to and/or obtain information.

Email of Individual Provider

Phone of Provider

Address of Provider

Address Line 1

Address Line 2

City

State

Zip Code

Description of Information to be Disclosed as Indicated by Client

Please specify purpose of the release, if other than as specified above.

Revocation (please check all to indcate agreement):

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to the provider.
I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Signature of Client

Clear Signature

Signature of Parent/Guardian

Clear Signature

Date / Time