Innovative Psychology Counseling Services
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Authorization for release of Information
Client Name
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Date of Birth
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Address
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Phone Number
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I, on behalf of myself or my child, hereby authorize Innovative Psychology Counseling Services, Inc. to exchange information with:
Agency and/or Person, Address & Phone Number
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Information to be disclosed:
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Mental Health Evaluation
Biopsychosocial Assessment and History
Alcohol and Drug Evaluation
Diagnosis and Treatment Plan
Progress Notes
Clinical Case Summary
All-of-the Above
The exchanged information will be for the purpose of collaboration of care and services for wholistic client treatment and best client clinical outcomes.
Signature (Client 12 years and older)
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Date
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Parent/Guardian (sign if client is under the age of 18 years old)
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Authorization for release of Information
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