Psychotherapy and Psychological Assessment
Phone: 973.734.0780

Consent to Release Confidential Information

    Re: Name
    D.O.B.
    To:
    Street
    City
    State
    Zip Code
    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 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:

    This information is needed for the following purposes:

    Name of therapist at IFC:
    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.
    Signature of Patient, or Parent/Guardian if Patient is a Minor
    Date

    The Institute for Change