Release of Information

Authorization for Release/Exchange of Information

This form provides your therapist with written permission to communicate with other individual providers regarding your treatment (e.g. previous treating therapist, current health care providers, parents or school).

Date of Birth

Client Last name

Thanks for submitting!

I authorize my therapist, Beth Holt Wright, to release/exchange the following information to:

Client First Name

Name

Phone Number

Address

Indicate which of these items can be released with a "yes" and those you do not want released with a "no."

Screening Information

Behavioral and Psychological Reports

Treatment Plan

Counseling Notes

Coordination of Care

Intake and History

Records from Alcohol / Drug Treatment Programs

Clinical Records from Mental Halth Programs

HIV / AIDS Related Information

Date

In providing your electronic signature, you agree that an emailed or electronic signature shall be the equivalent of an original signature on this agreement in accordance with the Uniform Electronic Transactions Act, Virginia Code Section 59.1-479, et seq.

Other

Signature