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Download lake city counseling, llc - Lake City Counseling in Madison, Wisconsin
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LAKE CITY COUNSELING, LLC Family Attachment Therapy Program 2829 Royal Avenue, Ste 200 Madison, Wisconsin 53713 Release of Client Information AUTHORIZATION Be sure all lines are filled in before you sign this form. Be sure the release is in your best interest. You have a right to inspect and receive a copy of the materials disclosed. The information to be released to the agency/individual as specified below cannot be passed to any other agency/individual without your authorization, unless otherwise required by law. A copy of this authorization may be used in lieu of the original. I authorize and request Lake City Counseling, LLC to: (check one or both) Release to Agency/ Individual _________________________________ Address Obtain from Phone__________________ ____________________________City_____________State_____Zip_____ The following specific information from the records of: Client’s Name ____________________________________Date of Birth_____________ Specific Information to be released by Lake City Counseling, LLC Release format: Verbal Written Client Information Progress reports Recommendations Specific Information to be released by Lake City Counseling, Drinking/drug history Medication History LLC Discharge summary Release format: Verbal Written Intake assessment Diagnosis Other______________________ Client Information Progress reports Recommendations For the treatment time period of (list dates): from ___/___/____ to ____/____/____ Drinking/drug history Medication History Discharge summary Specific Information to be RELEASED TO Lake City Counseling, LLC Release format: Verbal Written Progress reports Treatment history Social history Legal information Recommendations Discharge summary Psychiatric evaluation Drinking/drug Psychological evaluation Diagnosis Behavioral information Medication history Other___________________________________________________________________ The information relates to services received for: chemical dependency, mental health etc. ________________________________________________________________________ Purpose or need for Information: ________________________________________________________________________ This authorization expires in one year of this date or specific action: ________________________________________________________________________ This authorization can be revoked at any time prior to this date or action by providing written notice to Lake City Counseling, LLC. I understand that any information released prior to revocation cannot be retrieved and Lake City Counseling, LLC will not be held responsible for such. I hereby release Lake City Counseling, LLC from all legal responsibilities or liability that may arise from this act. ___________________________________________ Client’s signature Date ___________________________________________ Witness Date _____________________________________ Parent’s/guardian signature Date
