Reciprocal Release of Information



Jennifer Daniels PhD, LCPC
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085
(224)225-9650 | jennifer@jdanielsphd.com
jdanielsphd.com

 

 

Reciprocal Release of Information

Client’s Name:  

DOB:  

Address:  

City : State:   Zip:

Phone:  

Email:  

 

I  authorize Jennifer Daniels PhD, LCPC
  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:

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Signature Certificate
Document name: Reciprocal Release of Information
lock iconUnique Document ID: 136745d9fab5f5f871597775d9e91760bc887afb
Timestamp Audit
August 5, 2021 8:54 pm CSTReciprocal Release of Information 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