Authorization to Disclose Information

If you would like us to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.,) complete this form to authorize release of psychotherapy information.

  • Client Information

  • Recipient Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Information To Be Released

    (Note: Requests for release of psychotherapy notes cannot be combined with any other type of request.)