Release of Confidential Information

On occasion, you may want me to communicate with a third-party about your confidential information. Your written authorization is required in these cases (with some exceptions which are clearly explained up front at the start of therapy).

There may be times when you need me to speak to someone right away, but are unable to make a separate trip to my office to provide me with your written consent. In this case, you can download the necessary form here in a PDF file, print it, complete it, sign it and fax it back to my confidential fax number and/or send the hardcopy to me by mail.

Note: this form is not part of the regular intake package. Completing this form is only for those occasions when you may want me to communicate with a third party.


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