Consent and Authorization for Release of Information

If there are other parties that may assist in your therapy, and you believe it would be helpful for your therapist to contact them regarding your treatment, please read carefully and complete this document. The following is an authorization for the stated parties to consult with one another regarding your treatment process. Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the necessary information and your signature with today’s date as indicated below. I, (client), hereby authorize Marlee Dent, LPC, NCC (Counselor) and the following party or parties to discuss my mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to, therapist’s diagnosis:

Limitation on information shared: Additionally, the below named parties, therapist & person(s) or entity (entities) designated below, agree to exchange information only between themselves (or their agents). Any disclosure of information extended beyond these parties is considered a breach of confidentiality. Your signature below indicates that you understand that you have a right to receive a copy of this authorization. Your signature also indicates that you are aware that any cancellation or modification of this authorization must be in writing, and you have the right to revoke this authorization at any time unless the therapist stated above has taken action in reliance upon it. Additionally, if you decide to revoke this authorization, such revocation must be in writing and received and acknowledged in writing or email by Marlee Dent, LPC. Please note that treatment is not conditioned upon your signing this authorization, and you have the right to refuse to sign this form.

Your Name

First Name

Last Name

Email

Phone

(###)

###

####

List up to 3 third parties below (only one name is required on this form)

1. Name of third-party individual for information release

First Name

Last Name

Relation to Client

2. Name of third-party individual for information release

First Name

Last Name

Relation to Client

3. Name of third-party individual for information release

First Name

Last Name

Relation to Client

Please indicate your preference regarding the information to be shared, select one option below

Option 1: WITHOUT LIMIATIONS: The parties listed above may discuss my medical and/or mental health information without limitations.

Option 2: WITH LIMITATIONS: I would prefer to limit the information shared between the parties stated above. The limitations I would like to make are as follows:

If Option 2 was selected above please list the limitation(s) on information to be shared. Please provide as much detail as possible.

Electronic Signature

Please type your full name as signature and electronic consent for the attached form.

Date

MM

DD

YYYY