The Interpersonal Healing Clinic, LLC

1006 Depot Hill Rd., Ste. D

Broomfield, CO 80020

Office: (303) 514-4058

Fax: (303) 482-1331





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_____________