Consent to Release Confidential Information

To:

Below please indicate whether the information is to only be released to IFC or if IFC can also share information [exchange with] with the above-named entity:

I hereby authorize you to release toexchange with 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 is limited to:
Length of time in treatmentDiagnosis, description of progress and prognosisTreatment recommendationsDischarge or closing summaryMedical historyCopy of reportsBehavioral ObservationsOther:

This information is needed for the following purposes:
Diagnostic and evaluation purposesTo provide on-going treatmentOther:

Name of therapist at IFC: —Please choose an option—Andrea Peyser, LCSWBrenda Forte, LCSWDavid Szmak, PsyDJane Holzman, LCSWJanice Harris, LCSWRon Handelman, Ph.D.Therese Felcher, LCSW

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 in reliance on my consent.