Daily DBT - Release Form

Authorization for the Release and Exchange of Information

I authorize Daily DBT to release and exchange information about my case with the following parties:
Name:
Relationship:
Phone Number/Email:
Name:
Relationship:
Phone Number/Email:
Information to be Released or Exchanged
(check all that apply)

All relevant clinical informationIntake and historyDiagnosis and Treatment PlanTreatment ProgressBilling & PaymentAttendance OnlyTreatment SummaryOther
This release shall be valid until the termination of treatment or until withdrawn in writing during the course of treatment.
Client Name*
Signature

Clear
Date

MonthDayYear
Date
FOR MINORS ONLY:
Parent/Guardian Name
Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

FOR MINORS ONLY: