Release of Information Form

Release of Information

Authorization and Consent For Court Testimony or Deposition
Today's Date*

MonthDayYear
Date
Clinician's Name*
Client's Name*

First NameLast Name
Client Birth Date*

MonthDayYear
Date
Who is completing this authorization form?*

The clientLegal guardian or parent for the client
If not client, name of person completing form

First NameLast Name
I am authorizing the clinician indicated above to provide expert testimony pertaining to*

Me (for adult clients).The client identified above (for parents or legal guardians of the client).
By signing and completing this form, I give the above-identified clinician permission to provide expert testimony regarding the client also listed above in a court of law, and/or during any depositions, discovery, other trial or hearing-related situations, or any court or litigation administrative needs. This permission to disclose any and all information regarding my evaluation or treatment includes no exceptions, including but not limited to psychological testing results, information regarding therapy, and/or psychological testing raw data.

I understand the need for, and the implications of, this authorization for release of information, and this authorization and request to release information is being made voluntarily on my part. I understand that I may revoke this consent in writing at any time except to the extent that action based on this consent has already been taken. I understand that unless I revoke this release, it remains effective until the expiration date below. I further understand that should I revoke this release in the future, my clinician still might be required to testify about me and my case, if ordered to do so by any court of law.
Release Expiration Date*

MonthDayYear
This release can only be valid for up to one year from now.
Client Signature (for adults) or Legal Guardian/Parent Signature (for children) *

Clear
Should be Empty: