Willow Young, LMFT, JA

805.680.2406
WILLOW@WILLOWYOUNG.COM
WILLOWYOUNG.COM

22 West Micheltorena Street, Suite A West, Santa Barbara, CA 93101
790 Santa Clara Street, Suite 106, Ventura, CA 93001

authorization to release confidential information

I, (Name of Patient)

Hereby authorizes (Name of Provider)

To release confidential information obtained during the course of my treatment to (name or function of the person(s) or entities to whom information is to be released)

This authorization permits the release of the following information

Please check all relevant boxes and initial below.

Diagnosis

Treatment Plan

Progress to Date

Prognosis

Clinical Test Results

Dates of Treatment

Any and All Information Necessary

Other (specify)

I authorize the release of the information described above for the following purpose(s)

The specific uses and limitations on the types of information to be released are as follows

The specific uses and limitations on the use of the information by Recipient are as follows

I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. The authorization shall remain valid until the date below

Please initial below.

Patient (or Patient Representative) Signature

Please type your name. Your printed name indicates that you have read this agreement for services carefully and understand its contents.

Date

YYYY

Therapist Signature

Date

YYYY

Willow Young, LMFT, JA

805.680.2406WILLOW@WILLOWYOUNG.COMWILLOWYOUNG.COM

authorization to release confidential information

805.680.2406
WILLOW@WILLOWYOUNG.COM
WILLOWYOUNG.COM