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Overview
Types of Therapy
Mental Health Disorder
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Forms
Release Of Information
Janneta Bohlander & Associates, LLC
Janneta Bohlander, LMFT
83 East Avenue, Suite 208
203-521-0805
Janneta Bohlander, LMFT
CT license number 000955
Tax ID 20-3204106
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Authorization for Release of Information
Client’s Name:
*
DOB:
Information to be released:
Summary of treatment to date
Report
Other:
Purpose of Disclosure
Coordination of Care
Other:
Persons authorized to make Disclosure:
Person authorized to receive Disclosure:
Method of Disclosure
Written :
Verbal:
Electronic:
Today’s date:
Authorization to expire on:
I understand that my health information is protected by law. I authorize the release of my confidential health information as indicated above. I understand that my consent is voluntary and I can revoke this permission at any time, except to the extent that it has already been shared based on this authorization. Should I choose to revoke this authorization I will state this in writing.
Date:
Submit
