Consent For Release of Mental Health Information

Client Name_______________________________________________
Date of Birth:_________________
Mental Health Provider: Lee Hasty LCSW
Primary Care Provider Name: _________________________________
Practice Name: ____________________________________________
    Address: _____________________________________________
    Phone: ______________________  Fax:____________________
Initial Your Preference Below:

________ I authorize the release of relevant treatment information to the provider named above.  I
understand that the records are confidential and cannot be disclosed without my written
authorization, except as otherwise provided by law.  My consent can be revoked at any time.

________ I decline the release of treatment information to my primary care physician.

____________________________                _________________
Signature of Patient/Guardian                Date

Relationship to Client

____________________________                __________________
Witness                                                Date