Release of Information | Raising Brain

Release of Information Form

Raising Brain Home Harmony Coaching www.raisingbrain.org

This form provides your Ashley Bobst, LPN, NAC-HWC, with written permission to communicate with other individual providers regarding your treatment (e.g., current/previous treating therapist, current health care providers, parents or school)

Client First Name

Client Last Name

Client Date of Birth

Month

Day

Year

Parent/Guardian First and Last Name

I, [Client named above], authorize Ashley Bobst, LPN, NAC-HWC, to release and/or exchange the following information with the individual(s) or organization(s) listed below:

Name

Phone Number

Address

Information to be released:

Intake and History

Coordination of Care

Session Notes

Other

This release of information will remain in effect until the termination of treatment or until the client provides written notice to hello@raisingbrain.org to revoke this authorization, whichever occurs first.

This authorization may be revoked at any time

Client / Guardian Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year