Release of Information

This form is to be completed in the event that you wish to include other angecies or people previous therapists, medical providers, testing results, parent providing payment, or anyone else you would like for Accepted Therapy Sercies to have access to.

I   whose date of birth is  authorize Accepted Therapy Services to disclose and/or obtain information from  

The following information (initial each item to be disclosed)

Psychotherapy notes will not be released without discussion and approval from individual therapist.

This information may be used or disclosed in connection with mental health treatment or payment. If the purpose is other than as specified above, please specify


Unless sooner revoked, this authorization expires 60 days from the termination of my therapy services I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification my therapist at 423 Weathersby Road Suite 240 or by email to I further understand that revocation will not apply to actions taken by the requesting person/entity prior to the date they receive you written request to revoke authorization.


I further understand that Accepted Therapy Services will not condition my treatment on whether I give authorization for the requested disclosure.