Mental Health Care Release of Information Google Form Template

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Please complete this form to authorize the disclosure of your mental health care records to designated parties. Your privacy is important to us.

Email *

Record my email address with my response

Authorization Type *

Select whether you are initiating a new release of information or revoking an existing authorization.

Initial Authorization

Modification to Existing Authorization

Revocation of Authorization

Client Full Name *

Enter your full legal name.

Date of Birth *

Enter your date of birth.

YYYY

Disclosing Party / Facility Name *

Name of the mental health provider or institution releasing the records.

Receiving Party Name *

Name of the person, organization, or facility receiving the records.

Receiving Party Contact Information *

Provide the address, phone number, and email or fax of the receiving party.

Purpose of Disclosure *

Select the primary reason for releasing this information.

Information to Be Disclosed *

Select all types of records you authorize for release.

Psychotherapy Notes

Diagnosis and Treatment Plan

Attendance and Progress Summaries

Psychological Testing Results

Discharge Summary

Required

Authorization Expiration Date *

Specify the date or event upon which this authorization expires.

YYYY

Client Acknowledgment & Signature *

By typing your full name below, you confirm that you understand and voluntarily authorize the release of your confidential mental health information as specified above.

Date Signed *

Enter today's date.

YYYY

Send me a copy of my responses.

Submit

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