AUTHORIZATION FOR RELEASE OF INFORMATION This form is to be completed and signed by clients or parent/guardian, if client is a minor. A signed form authorizes the release of requested information from your clinical record to an individual or facility.Client Name First Last Date Of Birth MM slash DD slash YYYY Parent or Guardian Name (if client is a minor) First Last I hereby authorize: Release to Obtain from Exchange with Name of Person First Last Name of AgencyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I understand that this material is confidential and will become part of my records with the authorized person or agency, and that it will not be shared with other agencies without written permission. However, I also understand that records are subject to review by a person’s agency supervisor.Information to be shared: Diagnostic Reports Psychiatric Evaluations Medical Records Progress Reports Psychological Assessments School Records Treatment Plans Discharge Summary Other Other Please forward information to: Brave Soul Counseling Services 445 Broadway Avenue, Suite A St. Paul Park, MN 55071 Fax: 651.340.2587 This authorization is valid for one year after the date signed unless indicated otherwise. This authorization may be canceled in writing at any time. I understand that I may refuse to sign this authorization and that refusal to sign will not affect treatment.Client Signature*Date* MM slash DD slash YYYY CAPTCHA
