Authorization to Release and Receive Information for Child(ren) and Collaterals in Treatment

Dr. Tracy Bennett Psychological Services, Inc.

Tracy Bennett, PhD
Licensed Clinical Psychologist, PSY15696
340 Rosewood Avenue, Suite A
Camarillo, CA 93010
DrTracy@DrTracyBennett.com
805-383-0882
Authorization to Release and Receive Information for Child(ren) and Collaterals in Treatment
Child in Treatment*

First Name Last Name
Second Child in Treatment (if applicable)

First Name Last Name
Third Child in Treatment (if applicable)

First Name Last Name
Fourth Child in Treatment (if applicable)

First Name Last Name
I, the undersigned, hereby authorize the party(ies) named below to exchange information with Dr. Tracy Bennett about myself AND my child(ren), named above.

Specific information that I authorize for release and receipt is detailed below. Checked items may include records and/or anything said in session by myself or my child. Information that may have been integrated into the medical file may also include content shared via email, posted mail, or text.

Dr. Bennett will preserve the confidentiality of such information according to the policies based on applicable portions of the California Welfare Institutions Code Section 4514.
I give permission to Dr. Tracy Bennett to release to and obtain information from the following party(ies) (up to 4 parties):
Party to/from which I authorize release/receipt*

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Second party to/from which I authorize release/receipt (if applicable)

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Third party to/from which I authorize release/receipt (if applicable)

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Fourth party to/from which I authorize release/receipt (if applicable)

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Information to be exchanged include (Check all that Apply)

Information relevant to coordinating care (including but not restricted to attendance, diagnosis(es), and treatment plan)Statement of progress including participation and termination detailsTreatment summaryFinancial statementsAll records excluding treatment notesAll records including treatment notes
I understand that that this release is valid for the extent of treatment unless revoked in writing. I further understand that I may revoke this authorization at any time in writing. If you wish this release to be valid for a shorter term, please indicate the date it shall expire: DO NOT ENTER A DATE HERE UNLESS YOU WANT A SPECIFIC EXPIRATION DATE
Print your name*

First Name Last Name
By signing below, I show that I have read and understood the terms of this release of information. I understand that Dr. Bennett does not have control over what happens to records after their release to other parties. In consideration of this consent, I hereby release Dr. Tracy Bennett from any legal liability resulting from the release of this information. *

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