Consent to Exchange Information

Clients Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Authorize (Releasing Agency/Persons):

First NameLast Name
Address of Releasing Agency/Persons

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To Disclose or Exchange information with (Releasing Agency/Persons):

First NameLast Name
Address of Releasing Agency/Persons

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following information, with the knowledge that such contact discloses the fact that named person has received the services of the releasing agency. The disclosure of records is required for:
Other purpose (specify):

EvaluationTreatment PlanningOther purpose (specify):
Specify other purpose:
The release information to be used only for the purpose(s) agreed to by client (or guardian).
Legal StatusPsycho. & Vocational Test resultsDiagnosisMed. Indo indo. Med Test resultsPertinent summary of psychosocial and psychiatric historyEducational AssessmentTreatment Summary
This consent is subject to revocation by the client (or if a minor, by the consenting parent/guardian) at any time.
Signed:

Clear
Date

MonthDayYear
Date
Should be Empty: