Release of Information - Mental Health - Staff Requested

Staff Requesting Signature

eMail of Staff Requesting Signature*

Name of Staff Requesting Signature*

First Last

Client & Release Information

Today's Date*

Are you requesting a signature from the client or the parent/guardian?*

Client
Parent/Guardian

Client Name:*

First Last

Client's Date of Birth*

Name of person who will sign the form*

This may be the client, or the parent/guardian.

First Last

Email of Person Signing Form:*

This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email.

Agency/Person for whom the release is being signed

Are you requesting a release for a personal contact like a significant other, or a business/agency? *

Personal Contact
Business/Agency

Agency Name:

Required if "business/agency" is selected above.

Contact Person's Name:

Required if "personal contact" is selected above.

First Last

Contact Phone:

Contact eMail:

Contact or Business/Agency Address:

Street Address Address Line 2 City State ZIP Code

Nature & Purpose of Disclosure

How would you like to exchange information with this contact? **

provide to
receive from
exchange with

What type of information would you like to exchange?*

The most common options are pre-selected. Please check/uncheck options to match your preference.

Other information type:

In what format may would you like to exchange information?*

Verbally
In-Person Conference
Written Questionnaire
Mailed/Faxed Correspondence
Secure/Encrypted eMail

Purpose for disclosure:*

Assessment/Intake
Referral
Treatment Planning
Case Coordination
Discharge Planning
Consultation
Other:

Expiration of Authorization

Typically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here.

I Don't Need to Change the Expiration
Enter a Different Date

Alternate Expiration Date

Name

This field is for validation purposes and should be left unchanged.