Release Authorization - Brave Soul Counseling Services

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

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 Agency

Address

Street Address Address Line 2 City 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*

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