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Authorization for Release of Treatment
This form is to be used when you want Art Therapist Lynn Cukaj to release treatment information to any pertinent individual in your care.
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Today's Date
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MM
/
DD
/
YYYY
Client's Full Name
*
Your answer
Parent/Guardian's name if client is a minor
Your answer
I hereby request and authorize Lynn Cukaj to release the following information:
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Intake, assessment(s), progress reports, summaries, and treatment recommendation
Photographs, copies and/or scans of artwork
Other:
Required
To be released to: (Please include practitioner's name, the name of agency, full address, phone number, and email)
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Your answer
I give permission for this information to be used for the following purpose:
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Your answer
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