I, , authorize Metamorphosis Psychotherapy & Counseling to:

    Please select all that applies:

    Release to:

    Obtain Information:

    Exchange Information With:

    Release, Obtain or Exchange the Following Information Pertaining to Myself :

    Treatment Summary

    History/ Intake

    Diagnosis

    Psychological Test Results

    Psychiatric Evaluation/ Medication History

    Dates of Treatment Attendance

    Other (Specify)

    Release Information for the Purpose of:

    Evaluation/ Assessment and/or Coordinating Treatment Efforts

    Other (Specify)

    I DO NOT want my information disclosed to any party without my consent

    This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date. This form cannot be used for the re-release of confidential information provided to Metamorphosis Psychotherapy & Counseling by other individuals or agencies. Such requests should be referred to original individual or agency. I understand I have the right to refuse to sign the form, and that I may revoke my consent at any time (except to the extent that the information has already been released).

    ex. 01-15-2019

    ex. 01-15-2019