Release of Confidential Mental Health Information

Release of Confidential Mental Health Information

Client Name

Social Security Number (verification purposes)

Date of Birth

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals of family members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below

Name of person

Phone Number

Relationship to Patient

Confidential Communication: Communication between Jordan West Family Counseling and you, the client is critical to your well-being. Please list the phone number(s) where we can reach you, your parent(s) or guardian.

Name of person

Phone Number

Relationship to Patient

Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination.

Client Name

Relationship to Patient

Signature

Clear

Date

Date Hour Minutes AM/PM Option

Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.

This agreement is terminated as of

Jordan West Family Counseling Version 07-2012