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Release of Information – Mental Health – Staff Requested – GForm

Use this form to request that your client or their parent/guardian sign a specific release of information. Please check with the Office Manager/Admin to determine if this form has been signed/received.

Staff Requesting Signature
eMail of Staff Requesting Signature*
Name of Staff Requesting Signature*
First Last
Client & Release Information
Today's Date*
MM slash DD slash YYYY
Are you requesting a signature from the client or the parent/guardian?*
- Client
- Parent/Guardian
Client Name:*
First Last
Client's Date of Birth*
Name of person who will sign the form*
This may be the client, or the parent/guardian.
First Last
Email of Person Signing Form:*
This may be the client or the parent/guardian. A signed copy of this authorization will be sent to this email.
Agency/Person for whom the release is being signed
Are you requesting a release for a personal contact like a significant other, or a business/agency? *
- Personal Contact
- Business/Agency
Agency Name:
Required if "business/agency" is selected above.
Contact Person's Name:
Required if "personal contact" is selected above.
First Last
Contact Phone:
Contact eMail:
Contact or Business/Agency Address:
Street Address Address Line 2 City State ZIP Code
Nature & Purpose of Disclosure
How would you like to exchange information with this contact? **
- provide to
- receive from
- exchange with
What type of information would you like to exchange?*
The most common options are pre-selected. Please check/uncheck options to match your preference.
- Assessments/Summaries
- Chemical Health Information
- Diagnosis
- Diagnostic Interview
- Medical History & Physical
- Neuro/Psychological Testing
- Case Plans/Notes
- Discharge Summary
- Medication Information
- Urinalysis/Lab Tests
- Emergency Contact
- Treatment/Case Plans
- Consultations
- Legal Information
- Psychotherapy Notes
- Other
Other information type:
In what format may would you like to exchange information?*
- Verbally
- In-Person Conference
- Written Questionnaire
- Mailed/Faxed Correspondence
- Secure/Encrypted eMail
Purpose for disclosure:*
- Assessment/Intake
- Referral
- Treatment Planning
- Case Coordination
- Discharge Planning
- Consultation
- Other:
Expiration of Authorization
Typically, releases of information automatically expire one year from the date signed. This allows us to share the necessary information for the duration of treatment involvement. If you wish to specify an earlier date of expiration, you may do so here.
- I Don't Need to Change the Expiration
- Enter a Different Date
Alternate Expiration Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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