This form when completed and signed by you (signature below), authorizes the designates person to release or obtain protected information to or from your clinical record to:

Client Name(s): ________________________________________________________

Client Date of Birth: _____________________________

Release of Information

I authorize my psychologist, Michael Conner, Psy.D or his staff  to release the following information verbally and in writing to: _____________________________________________________________________

(Please Initial)

_____  Screening Information                  _____  Behavioral and Psychological Reports

_____  Treatment Plan                            _____  Psychotherapy/Counseling Notes

_____  Other: __________________________________________________________

I authorize  _____________________________________________________________

to release the following information verbally and in writing

_____  Screening Information                  _____  Behavioral and Psychological Reports

_____  Treatment Plan                            _____  Psychotherapy/Counseling Notes

_____  Other: __________________________________________________________

I am requesting my psychologist to release this information for the following reasons:

______  To provide services and care, or ______  (other purpose) ____________________

This authorization shall remain in effect until

Expiration date: _____________________

This authorization may be revoked at any time. The only exception is when action has been taken in reliance on the authorization. Unless revoked this release shall remain in effect for the period reasonably needed to complete the request.  I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA privacy rule.

Name of Patient(s), Client(s) or Authorized person(s):

______________________________________________________________________

Signature of Patient, Client or Authorized person:

______________________________________________________________________

Representative's Authority: _______________________________________________

Description of Authority: __________________________________________________