Release- Consent and Authorization to Release Information
If there are other parties that may assist in your therapy, and you believe it would be helpful for me to contact them regarding your treatment, please read carefully and complete this document. The following is an authorization for the stated parties to consult with one another regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the necessary information and your signature with today’s date as indicated below.
I _____ (Type your name below), *
hereby authorize Julie L. Brown, LPC, MHSP, LLC and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist’s diagnosis: (Type party(ies) name(s), titles, and contact number(s) below). *
Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form. Please indicate your preference regarding the information to be shared (choose one): *
If you chose the second option, please state the limitations:
This agreement expires: (choose one) *
Confidentiality and Right to Cancel
Additionally, the above-named parties, therapist & person(s) or entity (entities) designated above agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these parties is considered a breach of confidentiality. Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received by Julie L. Brown, LPC, MHSP, LLC at 113 Stringer Street Chattanooga, TN 37405 to be effective.
Signature
Typing your name below serves as your signature and indicates your agreement to abide by the terms of this Consent and Authorization to Release Information contract.
Please type your name below to sign. *
Please indicate the date of your signature below. *
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