Clinician's Name *

First Name

Last Name

Patient's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Name of Parent or Guardian *

(For Minors)

First Name

Last Name

I hereby authorize the above named clinician to exchange information with the following person/agency/organization in order to facilitate the behavioral health services being provided to the named patient. *

Yes, I agree & authorize.

No, I do not agree or authorize.

Phone Number *

(###)

###

####

Fax Number

(###)

###

####

The following specific information and records requested are as follows: *

Medical Reports/Info

Evaluation Report

Treatment Summary

Psychiatric Evaluation

Medications

Behavioral Information

School Psychiatric Evaluation

Current IEP Summary

Other

I understand that I may revoke this authorization, in writing, at any time and that it will automatically expire in one year: *

One Year From Signature Date

MM

DD

YYYY

This authorization is a general authorization for the release of information and will not include the release of information related to personal drug/alcohol use, HIV/AIDS, or secually transmitted diseases without my express permission, as checked below: *

Yes, I give authorization.

No, I do not give authorization.

My signature below indicates that I fully understand this authorization and its contents. Further, I understand that I may revoke this authorization at any time during its one year validity, except to the extent that action based on this authorization has already taken place. *

Typing your name below equals signing form. Signature of Patient (if over 13)

First Name

Last Name

Signature of Parent/Guardian (for minors)

First Name

Last Name

Today's Date: *

MM

DD

YYYY