Consent for Release of Confidential Medical/Psychiatric, Substance Abuse or HIV Information

CMHS

Comprehensive Mental Health Services was founded in 1988. Since the beginning our plan has been to combine the personal attention of a private practice with the strength of a larger organization. Accordingly, we employ a broad range of clinicians, we offer a wide range of services and - within the practice - we contribute to one another's work.

(609) 737-7797

Patient Name

Date of Birth

Date of Treatment from

Today's Date

Referral Source

Address

Phone Number

I authorize Comprehensive Mental Health Services to speak with

Name of Referral Source

If, other, please specify

I understand that treatment services are not contingent upon my signing this release. I also understand that this consent is subject to revocation, in writing, at any time, except to the extent that the facility/provider has already taken action.

This authorization for release of information is valid from (date given below) until written notice by myself is given and actually received and processed by Comprehensive Mental Health Services.

Authorization for Release Date

Parent/Guardian Signature

Date

Patient Signature

(if 14 years of age or older)

Date

Clinician's Signature

Date

Your information will be encrypted.