Release of Information







    I hereby authorize LIKEMIND Mental Health & Wellness, Inc. to:

    • Release information to;
    • Obtain information from;
    • Exchange information with;

    Name (required)

    Phone

    Fax

    The information requested or authorized for release or exchange pertains to (check all that apply):
    Outpatient psychotherapySchool RecordsPsychological/Neuropsychological evaluationsFinancial disclosuresSchedulingPsychiatric medications/notesREFUSED

    This authorization is valid from this date , to the end of treatment. I may cancel this authorization by sending a written, signed, and dated request to the practice listed above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it, my clinician has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my mental health evaluation or treatment.

    Patient Name

    Date of Birth

    Patient Signature
    Date

    Guardian Signature
    Date

    Witness Signature
    Date