Authorization to Release and Receive Information for Child 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 and Collaterals in Treatment
Child's Name *

First Name Last Name
I, the undersigned, hereby authorize the party(ies) named below to speak to or release records to Dr. Tracy Bennett or obtain information or records from Dr. Bennett for myself AND my child, named above.

The information checked below may include anything said in session by myself, my child, and ANY OTHER COLLATERAL(S) PARTICIPATING IN SESSION, including other caregivers and parents. It also may include information emailed, mailed, or texted to Dr. Bennett for the purposes of my treatment. I understand that such information may be integrated into my medical file and that 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 records from the following party(ies) (up to 6 parties):
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

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

information relevant to coordinating care my attendance in therapy my diagnosis my treatment plan when treatment was terminated and why treatment summary financial statement only all records excluding treatment notes all 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 SPECIAL 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. *

Clear
Today's Date
Should be Empty: