Permission to Release Mental Health Record

Information to be Released

You are hereby authorized to furnish the following from my or my child's mental health record:

Please check all that apply -

PsychoEducational Testing

Release of Mental Health Record

Other

If you selected 'other', please include details below:

Client Name

Date of Birth:

Address:

There is a $45 administrative charge for the first 20 pages and $1 per page thereafter. *There is NO fee for record requests made by government agencies (i.e. Unemployment office, SSI, etc.)*

Release to (First & Last Name / Government Agency):

Address:

Phone

Client Signature / Legal Guardian

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Your information will be encrypted.

Permission to Release Mental Health Record

Information to be Released

Forever Hope Counseling & Educational Services, LLC