AUTHORIZATION FOR THE RELEASE OR EXCHANGE OF INFORMATION

Your full name: *

Full name of counselor or staff from Avedian Counseling Center: *

Information to be released or exchanged with (full name): *

Company name if applicable:

Your relationship to the person. For example: my therapist, my psychiatrist, my partner. *

Phone number of the person we can contact: *

Email address of the person we can contact: *

INFORMATION TO BE RELEASED OR EXCHANGED (select all that apply): *

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 Avedian Counseling Center 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.

Your full name: *

Date * +

Your signature *

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