Release of Information

Release of Information

Authorization Form
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Name

First NameLast Name
Name of person(s) or entities authorized to receive information from Solace Counseling Staff
Name of Client(s)
Client(s) Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relevant contact information of person(s) or entitles authorized to receive information
I authorize the following information to be released. (Please tap the information below to toggle between permission to include or exclude in the following list.)
Counselor (please select one)
I,{yourName}, hereby authorize {counselorplease} to release and/or exchange information with {nameOf}. Authorization is valid for seven years from signuature date, unless otherwise indicated, or until treatment is termined. A photocopy, email, or fax of this original shall be as valid as the original.

The information is otherwise confidential, and its use is limited to the treatment of {clientName}.
Signature
Solace Counseling and Anxiety Center
1828 ESE Loop 323 STE 101 & 304 Tyler

solacecounselingstaff@gmail.com | Office: 903-952-3757 | Fax: 903-561-8373
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