Mental Health Release Form
Please fill out the following form to authorize the release of your mental health information.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Recipients
*
Family Members
Medical Professionals
Therapist
Other
Name of Authorized Person
*
First Name
Last Name
Phone Number of Authorized
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Authorized
*
example@example.com
Address of Authorized
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Submit
Should be Empty: