Consent for Release/Exchange of Information

Authorization for Release/Exchange of Information

It is the policy of Shine Bright Counseling and Consulting, PLLC to hold all information received from or concerning clients in the strictest confidence. Shine Bright Counseling and Consulting, PLLC will not voluntarily release, obtain or exchange any information without permission of the client.

This document authorizes the release of confidential information about you to the person or entity stated and for the purpose stated. If you have any questions about the form and how it is used, please ask your counselor.

I hereby authorize of Shine Bright Counseling, PLLC, and to disclose
and/or exchange records and information regarding (name of child) .

The purpose of this communication is:

Diagnostic EvaluationCoordination of ServicesTreatment PlanningOther If Other, please specify

And shall include:

Electronic Consent

By clicking this box below, I give my consent with an electronic signature. I understand that I can revoke this consent at any time except to the extent that action has been taken in reliance hereon.

Client’s Signature

Date (MM/DD/YYYY)

Signature of Parent, Guardian or Legal Representative

Date (MM/DD/YYYY)

Submit Authorization for Release of Information