Psychotherapy and Psychological Assessment
Phone: 973.734.0780

Consent to Release Confidential Information

    Re: Name
    D.O.B.
    To:
    Street:
    City:
    State
    Zip Code
    I hereby authorize you to The Institute for Change information from my records or my child’s records with the understanding that this information will be considered privileged and confidential.
    I understand that the specific type of information to be disclosed includes and may not be limited to:

    This information is needed for the following purposes:

    I understand that I need not consent to the release of information in order to obtain treatment services. I choose to do so willingly and voluntarily for the purposes specified above. I understand that I may revoke this consent at any time by notifying my therapist in writing, except to the extent that action been taken in reliance on my consent. This consent will otherwise expire one year from the date indicated below.
    Signature
    Date

    The Institute for Change