I, ______________________________________________, hereby authorize
(Therapist) ___________________________________________
To Release _______ To Exchange ___________
information pertaining to my evaluation and/or counseling sessions with:
Name: __________________________________________________________________________
Address: ________________________________________________________________________ Phone:_______________________________ Fax:______________________________________
Description of Information to be released: ______________________________________________ _______________________________________________________________________________
Purpose of Disclosure:_____________________________________________________________ _______________________________________________________________________________
This authorization will expire on ____________ or (90) days from the date of termination of my Treatment. I have been informed that I may revoke this authorization by written or oral communication at any time. I certify that this form has been fully explained to me and that I understand its contents.
Client Signature/ Date of Authorization _________________________________________________
Witness Signature/Date of Authorization ________________________________________________