Spencer Psychology

Authorization to Release Information

Client Name:
Client Date of Birth:   



I authorize the exchange of healthcare information between Spencer Psychology and:
Note: Only one name per release. You can fill out multiple releases if needed. Exchange with:  

Relationship to Client:

Information to be Exchanged (Please check choice or write in details for “other”):

Purpose of Release:


This release does not authorize subsequent disclosure by its recipients. Authorization is valid for one year, unless otherwise instructed. I understand consent can be revoked by me at any time in writing, except to the extent that action has been taken in reliance on it by agents of Spencer Psychology.


Electronic Signature of Client/Parent/Guardian:  

Note: If client is 18 or over, client must sign this consent. A parent cannot sign on behalf of a child if the child is 18 or older.