Golden Sky Counseling Release of Information

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Email *

Client's First Name *

Client's Last Name *

Client's Date of Birth *

YYYY

Information to be released (check all that apply) *

Summary of treatment to date

Report

Testing

Other:

Required

Purpose of Disclosure (check all that apply)

Coordination of care

Transition of care

Other:

Person(s) authorized to make disclosure *

Relationship to the client *

Parent/Guardian

Spouse

Other family member

Healthcare Professional

Legal Representation

School personnel

Other:

Contact Phone Number *

Persons) authorized to receive disclosure *

Relationship to the client *

Parent/Guardian

Spouse

Other family member

Healthcare Professional

Legal Representation

School personnel

Other:

Contact Phone Number *

Approved method of disclosure *

Written

Verbal

Electronic

I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary, and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization, I will state this in writing. This consent form expires one year from the date of signature. *

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature.

Required

Client Signature *

Today's Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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