CONSENT FOR RELEASE OF INFORMATION
I, ______________________________________ date of birth ___________, do consent and authorize the
following by writing YES or NO by each section and completing all applicable blanks:
_______ any Attorney, Agency, Mental Health Center, Case Manager, Counseling Center, School System, Medical
Facility, Physician, Psychologist, Psychotherapist, Pastoral Counselor or other Counselor to provide the above named
Counselor any information about me concerning any illness, injury, medical history, consultation, prescriptions,
treatment plans, progress reports, testing and appraisals or other information from medical, social service, or
consultation records.
_______ communicate by telephone or in writing with my Physician, Case Manager, Attorney or Attorney’s
representative as needed to assist the other professional in working with me.
Name of professional ___________________________________________ Phone _________________
Address ________________________________ City __________________ State, Zip ____________
_______ release all of my counseling records to: Counselor ______________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone ______________________________________________________________________
_______ release my counseling records with the exception of ____________________________________
to: Counselor ______________________________________________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone ______________________________________________________________________
A photostatic copy of this authorization shall be considered as effective and valid as the original. At anytime, I may
make written request to withdraw this release of information. Such withdrawal must be presented to the therapist
to whom this consent was originally given.
____________________________________ _________________ _____________________
Signature of Client or Guardian Date signed Social security number
Name of minor client or adult client under guardianship is: _______________________________________
If Guardian, legal authority is as:
Parent ___ Custodial parent ___ Trustee ___ Court-appointed guardian __
If other, specify: ___________________________________________________________________
I, ______________________________________ date of birth ___________, do consent and authorize the
following by writing YES or NO by each section and completing all applicable blanks:
_______ any Attorney, Agency, Mental Health Center, Case Manager, Counseling Center, School System, Medical
Facility, Physician, Psychologist, Psychotherapist, Pastoral Counselor or other Counselor to provide the above named
Counselor any information about me concerning any illness, injury, medical history, consultation, prescriptions,
treatment plans, progress reports, testing and appraisals or other information from medical, social service, or
consultation records.
_______ communicate by telephone or in writing with my Physician, Case Manager, Attorney or Attorney’s
representative as needed to assist the other professional in working with me.
Name of professional ___________________________________________ Phone _________________
Address ________________________________ City __________________ State, Zip ____________
_______ release all of my counseling records to: Counselor ______________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone ______________________________________________________________________
_______ release my counseling records with the exception of ____________________________________
to: Counselor ______________________________________________________________________
Address ________________________________ City __________________ State, Zip ____________
Office Phone ______________________________________________________________________
A photostatic copy of this authorization shall be considered as effective and valid as the original. At anytime, I may
make written request to withdraw this release of information. Such withdrawal must be presented to the therapist
to whom this consent was originally given.
____________________________________ _________________ _____________________
Signature of Client or Guardian Date signed Social security number
Name of minor client or adult client under guardianship is: _______________________________________
If Guardian, legal authority is as:
Parent ___ Custodial parent ___ Trustee ___ Court-appointed guardian __
If other, specify: ___________________________________________________________________
| COMPASSIONATE CHRISTIAN COUNSELING |
____________________________________________________
| Donald L. McClune, Jr., 228 Deepwood Drive / PO Box 273, Pine Grove Mills, PA 16868-0273 Phone: 814-234-9667/ Email: donmcclune@yahoo.com |
| Copyright 2003 -2011 Compassionate Christian Counseling |