__________________________________ __________________
Patient
Name
Patient ID#
I authorize Solutions Counseling and Consultation Services to disclose, release, and/or obtain records to/from my primary care physician/group and my health insurance/behavioral health company/employee assistance program for the purpose of coordinating my treatment. In addition, I authorize Solutions Counseling & Consultation Services and any psychiatrist I may consult with regarding my treatment to communicate with each other. Any additional parties I have checked below and Solutions Counseling & Consultation Services may also communicate regarding information relating to my assessment, psychotherapy, notes, admission, diagnosis, social history, school data, psychological tests, and treatment progress for purposes of evaluation and treatment. I understand that confidentiality will be waived if mandated by law (such as child abuse) or to prevent a clear and present danger to myself and/or another. I am aware that Health Insurance Portability and Accountability Act (HIPAA) information regarding the privacy of my health information has been made available to me.
PLEASE CHECK ALL THAT APPLY: (include addresses, telephone/fax numbers)
( ) My spouse _______________________________________________________________________
( ) My family member(s) ______________________________________________________________
( ) My lawyer ______________________________________________________________________
( ) My previous therapist _____________________________________________________________
( ) My school district ________________________________________________________________
( ) My employer ____________________________________________________________________
( ) The person who referred me _______________________________________________________
( ) Other _________________________________________________________________________
I understand that this release must be
signed for any treatment with medication. I understand
that all medication information must be shared with my primary care
physician.
I understand my signature gives consent for
evaluation and treatment.
___________________________________________
____________________
Patient signature (14and
older)
Date
___________________________________________
____________________
Parent/guardian signature (if under
18)
Date
|
w:f/infor A Multidisciplinary Private Professional Practice rev. 4/03 |
||
|
Direct all correspondence to: |
WILLIAM G.
LEE, Ph.D. |
Brookside Professional Park |