1. I authorize the use or disclosure of the health information as described below.
2. I understand that any information disclosed may include information relating to Sexually Transmitted Diseases (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse and information obtained by Journey to Wellness Counseling from other providers. This authorization applies to health/ behavioral health information to be disclosed by Journey to Wellness Counseling.