I, the undersigned, hereby authorize the party(ies) named below to speak to and release records to Dr. Tracy Bennett and obtain information or my records from Dr. Bennett. Specific information that I authorize for release and receipt is detailed below.
The information checked below may include anything said in session by myself and any collaterals who join me in session. 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.