RELEASE OF INFORMATION FORM

Authorization for Release/Exchange of Information

A Release of Information (ROI) form gives your permission for your wellness coach to share relevant details with your other providers or family members that you'd like to include in your care. This allows both parties to coordinate care, share updates, and support your overall goals. You can choose what information may be shared and may revoke permission at any time.

Client First Name (If child, please list child's first name here)

Date of Birth required

Client Last Name (If child, please list child's last name here)

Parent/Guardian First and Last Name if Applicable

Phone

Select an Address

I hereby authorize Ashley Bobst, N.A.C. (Neuro-Affirming Consultant), with Raising Brain Neuro-Affirming Consulting to disclose and share the following information with my healthcare providers and care team listed below:

1. Information to be disclosed:

General information regarding consultations, assessments, and recommendations related to neuro-affirming care and support.
Social, emotional, and behavioral observations relevant to the client’s care.
Progress reports, treatment goals, and any other necessary information regarding the client’s support plan.

2. Purpose of disclosure:

To coordinate care and provide a holistic understanding of the client’s needs.
To ensure a collaborative and effective approach in supporting the client’s progress.

Please list the name, email address, and phone number of any provider(s) you would like me to share information with.

This Authorization is Valid Until Revoked by Client. I understand that I can revoke this authorization at any time providing written notice to Ashley Bobst, LPN, NAC-HWC with Raising Brain LLC. Revocation will not affect any information shared prior to revocation.

Or:

This Authorization is Valid Until

I understand that the information disclosed under this authorization is protected by privacy laws, including HIPAA (Health Insurance Portability and Accountability Act), and will be kept confidential.

By signing this form, I acknowledge that I understand the nature of the information being disclosed, and I consent to the release of this information as outlined above.

Your Signature

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