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, INC.
___________________________________________________________
| Donald L. McClune, Jr., 228 Deepwood Drive / PO Box 273, Pine Grove Mills, PA 16868-0273 Phone: 814-234-9667 / Fax: 801-457-2376 / Email: donmcclune@yahoo.com |
Copyright 2003 -2010 Compassionate Christian Counseling, Inc.