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Client's Name-________________ Birth Date:____________
hereby authorize Howard Pollack M.F.T. to:
release to: Name_________________________
receive from: Name____________________________
the information specified below with the knowledge that such release discloses the fact that mental health services have been/are being provided.
Disclosure information is required for (circle one): Evaluation, Treatment, or Other (Specify)_________________ Other (specify)
And will be limited to (circle one):Entire Record, Initial Evaluation, or Other (specify)______________
The information disclosure under this authorization may be subject to re-disclosure by the recipient if allowed or required by law. This authorization becomes effective (Month/Day/Year)_______________.
This authorization may be revoked in writing by the undersigned at any time except to the extent that action has already been taken. If not revoked, it shall terminate at the end of (check one):
Other Date ________________
I understand that I am to receive a copy of this authorization.
Date: ________________________ Month/Day/Year
Date:________________________ Parent/Guardian/Conservator (if applicable)
Howard Pollack M.F.T. ______________________
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