Without a signed authorization to release information, I will not talk to anyone about our sessions. This form is included so that you can authorize me to talk to someone else. If you do not have someone in mind, you can ignore it. You will need a separate form for each person or organization. You can get a printable copy here.

Release of Information

Client Name:____________________ DOB // Date: _/_/___

I, _______________________________ , (client, or parent / guardian) authorize the reciprocal release of confidential information of___________________________(Adult client’s name or name or minor child or adolescent) to/from Jim Colbert, M.Ed., LPC. By my signature here, I allow the identified agency / person to release confidential information to be used in the formulation of a comprehensive assessment and provision of services. I realize this information will be held in confidence and is privileged communication between the two agencies only, and will not be released further to any other person or agency without an additional authorization from this client.

Agency / Person Requested to Release Information: Information should be released:

_______________________________________________________________________________

___ Verbally ___Written _____ Photocopied / digital transcript _____ fax / email

_____Any Information to be released.

Mark items to be disclosed:
____Entire record as needed ____Consult only ____Social History ___Psychological Testing

____ Mental Health history ____ Evaluation / Summary ____Treatment Plan ____School Record ____Medical Record ____Education or School Testing ____Discharge Summary ____Medication Information / History or Log

Information to be released for the purpose of:

___ Consultation and development of comprehensive treatment plan ____Continuity of Care ____Enable Employer to make a Determination

____Bariatric Determination ____Other

_____________________________________ _________________________________

Parent or Guardian Date Jim Colbert, M.Ed., LPC Date

This authorization can be revoked at any time by written request and will expire one year from the above-signed date.

Release of Information

Client Name:______________________ DOB ____/____/____ Date: _____/_____/_____

Client Name:____________________ DOB // Date: _/_/___