RELEASE OF INFORMATION

AUTHORIZATION FOR RELEASE OF CLIENT INFORMATION

Client's Name-________________ Birth Date:____________

I, __________________________________

and/or_______________________________ Parent/Guardian/Conservator

hereby authorize Howard Pollack M.F.T. to:

release to: Name_________________________

Address______________________

receive from: Name____________________________

Address_________________________

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):

6 months

Other Date ________________

I understand that I am to receive a copy of this authorization.

Date: ________________________ Month/Day/Year

Client Signature_______________________

Date:________________________ Parent/Guardian/Conservator (if applicable)

Date:_____________________

Witness Signature_______________________

Date:___________________________

Howard Pollack M.F.T. ______________________

Date:___________________________

Release to What to Expect

Serving the Bay Area including: Oakland, Berkeley, Albany, El Cerrito, Walnut Creek, Lafayette, Orinda, Alameda, San Leandro, San Francisco, Alameda Co., Contra Costa Co., Marin Co.