Ivory AUTHORIZATION TO RELEASE MENTAL HEALTH INFORMATION

Client Name:*

First NameLast Name

Client Date of Birth*

MonthDayYear

Organization/Person To Which Client's Information May Be Released:*

Organization Address:*

Organization Phone Number:*

Organization Fax Number:

Specific nature of information to be released:*

The information above is being released for the purpose of:*

facilitating consultation and/or collaborationfacilitating paymentfacilitating continuity of treatmentfacilitating family involvement in treatmentfacilitating scheduling/transportationOther

I understand that:

1. I have a right to a printed copy of this document.

2. I have the right to copy and inspect the information being disclosed.

3. I have the right to revoke this authorization, in writing, at any time, by sending such written notification to my provider’s office. My revocation will not be effective to the extent that my provider has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage, and the insurer has a legal right to contest a claim.

4. Treatment by Ivory Howell, LPCC is not necessarily conditioned on the signing of this document.

5. Once client allows release of information to any third party that there is a risk of re-disclosure by that party.

6. I am providing an electronic signature for this document and that I may request to sign a hard copy of this document if I prefer.

7. This consent will automatically expire in one year unless I specify another date below.

Expiration date of Authorization if lesser than one year from date of signature:

MonthDayYear

Signature of Client or Authorized Signee:*