I understand that my expressed consent is required to release any health care information relating to testing, diagnosis, and/or treatment of psychiatric disorders/mental health, as well as drug and/or alcohol use, from Crimson Dove Counseling Services, as well as any other such agency or medical practice from which I have received services. If I have been tested, diagnosed, and/or treated for psychiatric disorders, mental health, or drug and/or alcohol use, specifically authorize the release of all health care information relating to such testing, diagnosis, and/or treatment to/from the person or entity listed below.

I am giving this consent voluntarily and have been informed of the type of information requested. Information may be released in either written or verbal format. The benefits and disadvantages of releasing information have been explained to me. understand that provision of service does not depend on my decision concerning the release of information. However, in certain limited circumstances, due to the legalities of some service providers, I may be denied services if necessary consent is not given.

TIME LIMITATION OF RELEASE: This consent is valid until I complete or being discharged from Crimson Dove Counseling Services. I may revoke this consent at any time by signing the revocation section at the end of this document, except to the extent that information has already been released based upon it. I understand that if I am participating in the program as a formal condition of my parole, probation, or order of the court, I cannot revoke this authorization until the confinement, parole, or probation, is formally released on my behalf by such authority.