The Interpersonal Healing Clinic, LLC
1006 Depot Hill Rd., Ste. D
Broomfield, CO 80020
Office: (303) 514-4058
Fax: (303) 482-1331
RELEASE OF INFORMATION
I,____________________________, hereby authorize The Interpersonal Healing Clinic (IHC), LLC to release/exchange information pertaining to my evaluation and/or counseling sessions to:
Phone Number:______________________ Email:_________________________________________________
Such disclosure of information shall be limited to the following specific types of information:_____________________________________________________________
I understand that the IHC shall not condition treatment upon the signing of this authorization and I understand that I have the right to refuse to sign this form or revoke this authorization by written communication to my provider at any time.
I understand that authorization shall remain valid from the date of my signature below and for 9 months thereafter ending on: _____________________________.
I understand that I have a right to receive a copy of this authorization. I certify that this form has been fully explained to me and that I understand its contents.
Signature of Client _________________________ Date of Authorization_________
Signature of Guardian (if applicable)_________________________ Date _________
Signature of Therapist________________________ Date _____________
Signature of Witness_________________________ Date_____________