Consent For Release of Mental Health Information to Psychiatrist

Client Name_______________________________________________
Date of Birth:_________________ SS#________________________
Mental Health Provider: ______________________________________
Psychiatrist 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 psychiatrist.

________ I don’t have a psychiatrist

____________________________                _________________
Signature of Patient/Guardian                Date

Relationship to Client

____________________________                __________________
Witness                                                Date