Release of Confidentiality

By signing this form, I authorize the disclosure of information from Prime Counseling, LLC and its therapists to the following person/organization:

Name, Organization, Relationship, Address, and Phone Number:

________________________________________________________________________________________________________

This form also allows the aforementioned person/organization to provide Prime Counseling and its therapists with information to assist in the treatment of the client.

A. Unless otherwise specified below, any and all information regarding this client can be disclosed to assist in the treatment of the client. This can include, but is not limited to diagnosis, treatment, prognosis, chemical dependency, and/or medical knowledge including HIV health information

Please indicate if you do not want specific information disclosed: __________________________________________________________________________

B. The intended purpose of the release of information is for continuity of care. If other purpose, explain: _____________________________________

C. This authorization will expire after one year after client discharges from treatment, unless otherwise specified below: __________________________

D. Clinician cannot guarantee that the individual/organization contacted through this release of information will not disclose some or all of the information provided. The said individual/organization might not be bound by the same legal obligation to confidentiality as the treating clinician.

I understand I have the right to revoke this release at any time in writing. Client can send an email, text, or reach out to therapist to revoke this consent.

By signing below, I indicate that I have read, understand, and agree with the aforementioned information. I was given the opportunity to ask questions and was not forced or coerced into singing this document.

Client DOB: __________________________________________________________

Printed Name: _________________________________________________________

Signature: ____________________________________________________________