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RELEASE INFORMATION
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 Name
(Required)
Patient's Birthday
(Required)
Month
Day
Year
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)
Month
Day
Year
This authorization will expire 12 months from the date signed.
(336) 722-7266