Release of Information
By completing this form, I authorize Light on Anxiety CBT Treatment Center to release to, obtain from, or exchange information pertaining to: treatment summary, history/intake, diagnosis, psychological test results, psychiatric evaluation/medication history, dates of treatment attendance for the purpose of:
evaluation/assessment and/or coordinating treatment efforts. This document is valid for the time period that patient is under care of Light on Anxiety. In addition, I understand I have the right to refuse completing this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).

Note: For child clients, this release of information allows for exchange of information between therapist and child client when necessary and appropriate.

Email address *
Name of Client *
Your answer
Name of Legal Guardian if filling out for child client *
Your answer
Light on Anxiety Provider (Name) *
Your answer
Permission to speak to Provider (Name) *
Your answer
Provider (Phone Number) *
Your answer
Provider (Email Address)
Your answer
Electronic Signature of Patient or Legal Guardian of Patient *
Your answer
Date *
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