Release of Information – Resolutions Professional Counseling

Contact Information*
Resolutions Professional Counseling, PLLC Tara Fleis, LPC tfleis@resolutionsprofessionalcounseling.com 9885 State Hwy. M95, Republic, MI 49879 308 Cleveland Ave. Ste. 302, Ishpeming, MI 49849
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth*
Gender*
Phone*
May I leave a message for you at this number?*
- Yes
- No
Email*
Preferred forms of communication*
- Text
- Phone
- Email
This authorization is for the use or disclosure of health information.*
- I Agree
I hereby authorize your therapist to:*
- Communicate with
- Release Treatment Summary
- Release Clinical Record
Name of Person or Organization Receiving Information*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Purpose: The specified recipient may use the health information authorized on this form solely for the following purpose(s):*
Expiration: This authorization becomes effective immediately and shall expire on:*
Date Format: MM slash DD slash YYYY
My Rights:*
My Rights: ▪ I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment. ▪ The recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me, or unless the use or disclosure is specifically permitted by law. ▪ I reserve the right to withdraw or revoke this authorization, in writing, at any time, except to the extent that my therapist has already disclosed the information. ▪ I have a right to receive a copy of this authorization.
I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.*
- I Agree
Client Signature*
Type your full name
Date*
Date Format: MM slash DD slash YYYY