Release of Information

Release of Information

Authorization Form
Today's Date

Month Day Year
Date
Your Name

First Name Last 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, LPC-S Allison Cooper, LPC-S Zach Herrin, LPC-S Ashlee Coleman, LPS-S Russ Bailiff, LSCW-S Austyn Bailiff, LPC Holly Haswell, LPC-A, Supervised by Millie Tanner, LPC-S Rebecca Renfrow, LPC-A, Supervised by Allison Cooper, LPC-S Brian MacKenzie, LPC-A, Supervised by Millie Tanner, LPC-S Anjelica Reyes, Supervised by Millie Tanner, LPC-S Jaclyn Fahey, Supervised by Zach Herrin, LPC-S Kimberly Morris, Supervised by Ashlee Coleman, LPC-S Bianca Blattman, Supervised by Ashlee Coleman, LPC-S Caitlyn Lewis, Supervised by Zach Herrin, 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

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