Bradbury Counseling and Consulting

AUTHORIZATION TO RELEASE /EXCHANGE CONFIDENTIAL INFORMATION

This form cannot be used for the re-release of confidential information obtained by this agency by other individuals and or agencies. Such requests should be referred to the original individual or agency.

I _(name listed below)__authorize Bradbury Counseling and Consulting to:

First name

Last name

Date of birth

Month

Day

Year

Email

Dropdown

Please specify the release recipient's information here.

For the purposes of:

Coordination of treatment efforts

Assessment/ Evaluation

Other

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Today's Date:

Month

Day

Year

Consent will automatically expire one (1) year after signing or earlier as identified by the date below. I understand that I have the right to revoke my consent at any time (except to the extent information has already been released.

Initials

I declare that the info I’ve provided is accurate and complete.