Consent to Exchange Information

Clients Name:

First Name Last Name
Date of Birth

Month Day Year
Date
Authorize (Releasing Agency/Persons):

First Name Last Name
Address of Releasing Agency/Persons

Street Address

Street Address Line 2

City State / Province

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

First Name Last Name
Address of Releasing Agency/Persons

Street Address

Street Address Line 2

City State / 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):

Evaluation Treatment Planning Other purpose (specify):
Specify other purpose:
The release information to be used only for the purpose(s) agreed to by client (or guardian).
Legal Status Psycho. & Vocational Test results Diagnosis Med. Indo indo. Med Test results Pertinent summary of psychosocial and psychiatric history Educational Assessment Treatment 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

Month Day Year
Date
Should be Empty: