Involve Others in Your Treatment

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 Birthday(Required)

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

Names of friends or family that we can communicate with:

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
This authorization will expire 12 months from the date signed.