Reciprocal Release of Information | Carolynn Brusseau


 



Carolynn Brusseau, MA, LPC
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085
carolynn@jdanielsphd.com | 312-600-5367
jdanielsphd.com

 

 

Reciprocal Release of Information

Client’s Name:

DOB:

Address:  

City : State:   Zip:

Phone:

Email:  

 

I  authorize Carolynn Brusseau, MA, LPC
 to exchange information with the following person, program or facility:

Contact Person:

Address:

City :   State:     Zip:

Phone:   Fax: 

 

I agree to release the following information:

Psychological or psychiatric evaluation results

Psychotherapy notes/ Progress notes

Recommendations

Legal record/contact information

Educational plans/disciplinary actions

Any private health information pertinent to coordination of services

Other (please specify):

 

 

The purpose of this disclosure is:

Assessment and treatment planning

Coordination of care

Continuity of Care Other (please specify):

Other (please specify):

 

I understand I may revoke this consent at any time by giving written notice to Jennifer Daniels

If no prior of notice of revocation is received the consent will automatically expire one year from the date of consent. I understand that I have the right to inspect and copy the information disclosed.

Signature:  


Client signature 12 yrs & older (Type full name)

Parent/Guardian's Initials

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Reciprocal Release of Information | Carolynn Brusseau
lock iconUnique Document ID: 0f4e2c5b7a9698d1129cefd1085d4c368450034e
Timestamp Audit
May 9, 2023 11:27 pm CDTReciprocal Release of Information | Carolynn Brusseau Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP 72.207.59.93
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://jdanielsphd.com/
Audit Trail Serial# a3833dd72ff740ff46b2c12be698f836