Release of Information

Release of Information

Authorization Form
Today's Date

MonthDayYear
Date
Your Name

First NameLast Name
Name of Client(s)
Name of person(s) or entities authorized to receive information from Solace Counseling Staff
Relevant contact information of person(s) or entitles authorized to receive information
I authorize the following information to be released. (Please tap the information below to toggle between permission to include or exclude in the following list.)
Counselor (please select one)

Millie Tanner, M.A, LPC-SAllison Cooper, M.A, LPC-SZach Herrin, M.A, LPC-SAlexis Combest, M.Ed, LPC-S, RPT-S, NCC, ASDSRuss Bailiff, LSCW-SAustyn Bailiff, M.A, LPCHolly Haswell, LPC-A, Supervised by Millie Tanner, M.A, LPC-SRebecca Renfrow, M.A, LPCCourtney Gordon, LMFTEmilie Hanna, Supervised by Russ Bailiff, LSCW-SMary Graves, RPT,LPCCourtney Johnson, Supervised by Allison Cooper, M.A, LPC-SEsther Brown, Supervised by Allison Cooper, M.A, LPC-SMatt Ravanesi, Supervised by Millie Tanner, M.A, LPC-S
I,{yourName}, hereby authorize {counselorplease} to release and/or exchange information with {nameOf}. Authorization is valid for seven years from signuature date, unless otherwise indicated, or until treatment is termined. A photocopy, email, or fax of this original shall be as valid as the original.

The information is otherwise confidential, and its use is limited to the treatment of {clientName}.
Signature

Clear
Solace Counseling and Anxiety Center
1058 Asher Way, Ste 400 Tyler | 1828 ESE Loop 323, 3rd Floor Tyler solacecounselingstaff@gmail.com | Office: 903-952-3757 | Fax: 903-561-8373
Should be Empty: