Consent to Release Information for Therapy

This form allows Amy Person to speak to another therapist or provider on your behalf.

I requests and authorize the disclosure of mental health and relevant information about me between the following two people: Amy Person, LPC and:

This consent is for the purpose of case coordination and care. I understand that, by law, I need not consent to the release of this information; however, I choose to do so willfully and voluntarily. This consent can be revoked at any time by providing written notice to the above parties.