Therapy Release of Information Form

Client/Patient Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Therapist/Practice Name

Therapist Name

First NameMiddle NameLast Name

Practice Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Practice Email Address

example@example.com

Recipient Name or Organization

Recipient Phone

Please enter a valid phone number.Format: (000) 000-0000.

Recipient Email

example@example.com

Recipient Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Relationship to Client

Information to Be Released

Purpose of Disclosure

Date Range of Records to Be Released

Date

Preferred Method of Disclosure

Authorization Start Date

Date

Expiration Date

Date

Special Instructions or Limits on Information to Share

Release Duration