Release of Information with progress notes (Liberated Counseling)

Liberated Counseling, LLC
GENERAL CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
CLIENT NAME:*
DATE OF BIRTH:*

MonthDayYear
Date
THIS WILL AUTHORIZE: Liberated Counseling LLC

Tel. (505) 504-5449;email steve@liberatedcounseling.com
To RELEASE TO: (Facility, organization, individual receiving information)*
(Telephone, fax, address)
In authorizing this release of information, I understand it will be used solely for the purpose of *
both now and in the future.
HIV / AIDS results and treatments

Clear
Sexually transmitted or "communicable" disease Information

Clear
Prescription Drug Information

Clear
Drug, alcohol, or substance abuse Information

Clear
Mental health Information (other than psychotherapy notes)

Clear
Progress and Psychotherapy Notes

Clear
I understand that I have a right to meet with my clinician to inspect my mental health records and any information that will be disclosed. I further understand that this information cannot be re-disclosed without my express authorization. I understand that I may revoke this consent at any time except to the extent that action has already been taken.

This authorization shall remain valid for one year from the date of signature unless revoked in writing by the client's guardian or conservator. This authorization releases Liberated Counseling, LLC from any and all legal liability that may arise as a result of compliance with this release of information request.

TO THE RECEIVING PARTY OF THE INFORMATION: This information has been disclosed to you for the SOLE PURPOSE STATED IN THIS CONSENT. Any other use of this information without the express written consent of the client is prohibited. These records may be protected by Federal Regulation (42 CFR Part 2).

My signature below attests to the fact that I have read this form, understand its content and request that the above information be released as specified.
CLIENT SIGNATURE (14 YEARS OR OLDER)*

Clear
DATE*

MonthDayYear
Date
Partner Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Liberated Counseling, LLC

GENERAL CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION