Release of Information Form - O'Leary Counseling LLC

O'Leary Counselling, LLC

Release of Information

I hereby authorize the release and disclosure of the following clinical and/or therapeutic records for the following purpose(s):

Authorization to release information regarding counseling and therapy care and treatment.

Authorization to release information held under the Drug Office and Treatment Act of 1972 (PL- 92255) and the Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act Amendments of 1974.

Authorization to release information related to Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)

Please release authorization information between O'Leary Counseling, LLC and:

First Name

Last Name

Additional Healthcare Provider (please list their name, address, and phone number):

Please release authorization information between O'Leary Counseling, LLC and:

Name

Address

Phone

Specific information to be release (please initial appropriate information):

Assessment and evaluations Psychosocial history Continued care and treatment Discharge summary Attendance/Correspondence Billing information

Correspondence (please specify):

Phone Email Text

Purpose(s) for which information is to be released:

Revocation/Expiration: This Release of Information is subject to revocation by the under-signed at any time except to the extent that information has already been disclosed based on authorization contained herein. Unless further limited by a date stated here (below) this Release of Information will automatically expire after a period of 180 days from the date signed. I have the right to receive a copy of this Release of Information upon my request.

Revocation/Expiration Date:

Client/Guardian Name:

Date

Client/Guardian Signature

Therapist Signature

Date: