Release of Information

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
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3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Kentucky
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Maine
Maryland
Massachusetts
Michigan
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Mississippi
Missouri
Montana
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Nevada
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New York
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Which treatment partners would you like to allow us to coordinate your treatment with?
Primary Care Provider
Other Therapist
Psychiatrist or Psychiatric Nurse Practitioner
Pastor, Rabbi, Imam, or similar Faith Leader
7
Primary Care Provider's Name
First Name
Last Name
8
Primary Care Provider's Email
example@example.com
9
Primary Care Provider's Phone Number
Area Code
Phone Number
10
Primary Care Provider's Place of BusinessWhat is the name of the hospital or clinic where you see your primary care doctor?
11
Psychiatric Prescriber's Name
First Name
Last Name
12
Psychiatric Prescriber's Email
example@example.com
13
Psychiatric Prescriber's Phone
Area Code
Phone Number
14
Psychiatric Prescriber's Place of BusinessWhat is the name of the hospital or clinic where you see your psychiatric prescriber?
15
Faith Leader's Name
First Name
Last Name
16
Faith Leader's Email
example@example.com
17
Faith Leader's Phone
Area Code
Phone Number
18
Faith Leader's Place of Worship or PracticeWhat is the name of the church, synagogue, mosque, or other place of worship where you meet with your faith leader?
19
Other Treatment Partner's Name
First Name
Last Name
20
Other Treatment Partner's Email
example@example.com
21
Other Treatment Partner's Phone
Area Code
Phone Number
22
Other Treatment Partner's Place of Business
23
Other Therapist's Name
First Name
Last Name
24
Other Therapist's Email
example@example.com
25
Other Therapist's Phone
Area Code
Phone Number
26
Other Therapist's Place of BusinessWhat is the name of the agency, clinic, or private practice where you see your other therapist?
27
Release of InformationI authorize the mutual disclosure of the information to be released between the Restored Life Counseling and the above listed professional(s). I understand that the purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment, and coordinate treatment services. I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to Restored Life Counseling. I understand that a revocation of this authorization is not effective to the extent that action has been taken in reliance on the authorization. I understand that my treatment is not conditioned on whether I sign this authorization.
28
Signature
Clear
Should be Empty:

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