Consent Release Confidential Information

Download Consent Release Confidential Information Form

Or Fill in and Sign the Form Below

    I, , hereby authorize an exchange of information between the following agencies:

    1. Angie L. Heath, LCSW
    Clinical Conversations, Inc.
    5680 Peachtree Parkway, Suite B
    Peachtree Corners, GA 30092
    Fax: (470)375-7727

    The following items may be copied and/or provided:

    Treatment AttendanceDischarge SummaryPsychiatric ReportsDiagnosisVerbal CommunicationsLevel of ParticipationHistory & Physical Exam

    Psychological ReportsTesting ResultsTreatment PlanProgress NotesMedical ReportsAll items can be provided

    The disclosure of information is required for the following purpose(s):
    Coordination of Treatment OR


    I understand that this consent is revocable, in writing, at any time prior to its expiration which will occur
    Or:

    Client Signature: (Or Parent/Guardian signature if client is a minor)

    Client Contact Email:
    Client Name:
    Date: