Standard Authorization of Disclosure Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Description of Information to be Disclosed (Please check all that apply):

Assessment

Diagnosis

Psychosocial Evaluation

Psychological Evaluation

Psychiatric Evaluation

Treatment Plan or Summary

Current Treatment Update

Medication Management Information

Presence/Participation in Treatment

Nursing/Medical Information

Other

Purpose (Please check all that apply):

Educational Information

Discharge/Transfer Summary

Continuing Care Plan

Progress in Treatment

Demographic Information

Psychotherapy Notes

Other

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to my therapist. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization *

Yes, I Understand

I understand that unless sooner revoked, this authorization expires exactly one year from the date in which it was signed, or as otherwise indicated. *

Yes, I Understand

I further understand that [Be Here Now Mindfulness, LLC] will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences of not instituting continuity of care and leave client solely responsible for next steps in treatment care plan. *

Yes, I Understand

By checking this box I acknowledge that I have read and understand the information described herein and that I have been given an opportunity to have my questions answered on any part of the information I do not understand.

Yes, I agree and understand and give consent for disclosure.

Date

MM

DD

YYYY

Time

Hour

Minute

Second

AM PM