Treatment Involvement Form

If there are people whom you would like to be involved in your treatment, please list them and sign below.
This will give us permission to release information about your treatment, diagnoses (including substance-use diagnoses) and medical records if needed.

Patient's Name(Required)

Patient's Birthday(Required)

Names of doctors and therapists for us to coordinate care with:

Name of Coordinating Provider

City

Type of Provider

Name of Coordinating Provider

City

Type of Provider

Name of Coordinating Provider

City

Type of Provider

Names of friends or family that we can communicate with:

Name of Involved Person or Party

Phone

Relationship

Name of Involved Person or Party

Phone

Relationship

Name of Involved Person or Party

Phone

Relationship

Names of people we should not communicate with:

If there is anyone you want us to have no contact with, please list them here as an extra precaution

Name of Unauthorized Person or Party

Relationship

Name of Unauthorized Person or Party

Relationship

Name of Unauthorized Person or Party

Relationship

Signature of Patient (or Parent/Legal Guardian if under 18)(Required)

Date(Required)

This authorization will expire 12 months from the date signed.