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 |



Reciprocal Release of Information

Client’s Name:  



City : State:   Zip:




authorize Jennifer Daniels PhD, LCPC
 to exchange information with the following person, program or facility:

Contact Person:  


City :   State:     Zip:

Phone:   Fax:   


I agree to release the following information:

Psychological or psychiatric evaluation results

Psychotherapy notes/ Progress notes 


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.


Client signature 12 yrs & older (Type full name)

Parent/Guardian's Initials 

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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 CDTReciprocal Release of Information Uploaded by Jennifer Daniels - IP