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 the duration of the study, 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: