WPC - Coordination of Care

Full Name

Date of Birth

Most physicians recognize the benefits of psychotherapy for mental and physical wellness and appreciate the opportunity to coordinate treatment with your therapist. Please indicate your preference for treatment coordination below.

Do you want to authorize your therapist to coordinate care with your physician:

Yes, please coordinate care with my physician.

No thank you, I do not want my therapist to coordinate care with my physician at this time.

Physicians Name

My signature below authorizes Wandering Path Counseling LLC to exchange information as described above. I understand that my records are protected under federal and state confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. This authorization is valid only for the information, agencies, and person cited above and for no longer than one year after my signature date on this form. I understand that I may revoke this authorization at any time. I acknowledge that I am the client or the legal representative of the client, and I agree that my typed name is a legally binding equivalent to my handwritten signature.

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Date

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WPC - Coordination of Care

Wandering Path Counseling, LLC