Consent For Release of Mental Health Information
Date of Birth:_________________
Mental Health Provider: Lee Hasty LCSW
Primary Care Provider Name: _________________________________
Practice Name: ____________________________________________
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