FORM – Release of Information – Refreshing Waters Counseling

I hereby authorize Refreshing Waters Counseling to release my information to:
Released to name
Purpose
Field Group Open
Name*
Email*
Phone*
Relationship*
Field Group Close
Patient's First Name*
Patient's Last Name*
Patient Address
Patient City
Patient Zip
Patient State
Patient Phone*
Date of Birth*
MM
DD
YYYY
Field Group Open
I authorize the following information to be released from my records*
- All dates of service
- Single date of service
- A range of dates of service
All Dates
Through
Date of service
Date Format: MM slash DD slash YYYY
Date of service start
Date Format: MM slash DD slash YYYY
Date of service end
Date Format: MM slash DD slash YYYY
Field Group Close
Please select the appropriate item(s)*
- Initial Assessment
- Session Notes
- Treatment Plan
- Emergency Contact Only