Release or Request Form

Authorization for Release and Consent for Disclosure or Request for Medical Information or Records
Client Name:
Date of Birth:

MonthDayYear
I authorize Balance Counseling LLC to:

Release information to the individual/organization listed belowRequest information from the individual/organization listed below
Name:
Address:
For the following purpose, use, or need:
The following information from my psychiatric/medical records may be disclosed, including information about alcohol and/or drug use (in accordance with Federal Regulations CFR41, Part 2): diagnosis, prognosis, testing and/or treatment for HIV infection and/or AIDS virus:

TreatmentPhysical ExamPsychiatric EvaluationLaboratory StudiesPsychological TestingInitial AssessmentVerbal ConsultationExchange of all written and verbal pertinent informationEmailOther
I understand that this authorization may be withdrawn by me at any time. Revocation of this authorization will not affect any information already released. This authorization will remain in effect until terminated in writing.
Client Signature:

Clear
Date:

MonthDayYear
Balance Counseling
Ashley Gilbert LMSW, CAADC, EMDR
ashley.gilbert@balancecounseling.online
925 Grand Rapids St. Middleville, MI 49333
Should be Empty: