AUTHORIZATION FOR THE RELEASE OR EXCHANGE OF INFORMATION

Participant's Full Name *

Anger Management 818 Staff/Facilitator for information to be Released or Exchanged with: *

Information to be Released or Exchanged with (Full name and relationship to that person) *

Phone number and/or email address *

INFORMATION TO BE RELEASED OR EXCHANGED (select all that apply)- please note that progress reports require attendance records, court/agency documents, numbers of ordered sessions, participation and modality. *

This authorization shall become effective immediately and expire in one year from its effective date. A scanned copy, photocopy, or fax shall be considered as valid as the original.

Authorization of disclosure of your metal health information to someone who is not legally required to keep it confidential may be redisclosed and may not be protected.

YOUR RIGHTS:

1. You may refuse to sign this authorization.

2. You have the right to revoke this authorization by writing the AM818 Executive Director, Anita Avedian. The status of your revocation will go into effect after which time it has been received by the Executive Director and will not extend to information already obtained or released prior to the revocation.

3. You may receive a copy of this authorization upon request.

Participant name: *

Date * +

Participant signature *

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