Information Release Form Template

Client Name: ______________________________                File Number/Code:______

Date: ______________

I, ______________________________(client), give permission for _________________________(mental health practitioner) to:

• Receive my personal information.
• Release my personal information.

From/To:

(Please provide the name and contact details, along with any specifications regarding the information release below.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

For the duration of:

__________________ (Date start) until _____________________________ (Date end)

The aim would be to improve my care and maintain my best interest. I can withdraw this permission at any point in time.

I acknowledge and agree to the above information.

___________________

Client

In the event of the client being a minor, the therapist requires both parents to consent to treatment/therapy/assessment before moving forward with the first consultation.

________________________                  ________________________

Parent 1 Signature                                   Parent 1 Name

________________________                  ________________________

Parent 2 Signature                                   Parent 2 Name

DATED at ________________ on this ______ day of _________________

References:

Oregon Psychological Association. (2023). Release of Information Forms and Information. https://www.opa.org/release-of-information-forms-and-information 

You can download more Mental Health worksheets here.

Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.