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Release of Information

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Forms used in Psychotherapy Private Practice

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									AUTHORIZATION FOR THE RELEASE OR EXCHANGE OF INFORMATION

Client Name:______________________________DOB:_________________

Information to be Released or Exchanged with:

__History and Physical Exam __Discharge Summary __Psychiatric Evaluation __Psychological Test Results __Chemical Recovery History __Dates of Hospitalization __Court Agency/Documents __Mental Status Information __Treatment Plans __Progress Notes __Diagnoses __Crisis Intervention Reports __Medical Records __Educational Reports/Records __Other:_________________________________________________________

Client Name:_____________________________________________________

Client/Parent/Guardian Signature:______________________________________ Date:__________


								
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