THIS SITE IS UNDER CONSTRUCTION - Private Counseling




 

AUTHORIZATION FOR RELEASE OF INFORMATION

 

 

 

CLIENT NAME: ________________________________________

DATE OF BIRTH: _______________________________________
 

I HEREBY AUTHORIZE BETTY CARVAJAL, PhD , LMHC
TO RELEASE ANY MEDICAL, PSYCHIATRIC, PSYCHOLOGICAL LEGAL AND/OR EDUCATIONAL INFORMATION TO THE FOLLOWING PERSONS) AND/OR AGENCY AND TO OBTAIN SUCH INFORMATION FROM THE FOLLOWING PERSON(S) AND/OR AGENCY:

 

NAME: ______________________________________________________________



ADDRESS: ______________________________________________________________

 

 

FOR THE PURPOSE OF: ______________________________________________________________

 
BETTY CARVAJAL, PhD, LMHC  FOLLOWS ALL STATE AND FEDERAL LAWS TO MAINTAIN CONFIDENTIALITY OF PRIVILEGED INFORMATION.  THIS AUTHORIZATION WILL REMAIN IN EFFECT FOR A PERIOD OF ONE (1) YEAR FOLLOWING EFFECTIVE DATE AND IS SUBJECT TO WRITTEN REVOCATION AT ANY TIME.

 

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                               _________________ DATE__________
CLIENT SIGNATURE (PARENT/GUARDIAN)