Alison Hadley, MSW/DCSW

323 West 15th Avenue Spokane, WA. 99203 (509) 456-8199x3; Fax: 456-2080

Email: alison@alisonhadley.com / Web: http://www.alisonhadley.com/

Informed Consent for Disclosure of Mental Health Records and Information

Client name:

Birth date:

Social Security Number:

I hereby authorize Alison Hadley, MSW/DCSW, to release/exchange:

				purpose of information
	intake assessment/evaluation	progress notes		treatment planning		legal issues
	medication review notes	treatment plan		coord. treatment / referral		employment assistance
	other:			other:
Information to be released to:					Phone no.:
Address:
City:			State / ZIP:
I hereby authorize:
					Phone no:
Address:
City:			State / ZIP:

… to release to Alison Hadley, MSW/DCSW:

		purpose of information
intake assessment/evaluation	progress notes	treatment planning	legal issues
medication review notes	treatment plan	coord. treatment / referral	employment assistance
other:		other:

I understand that my records are protected under Federal and State Statutes and cannot be disclosed without my written consent, except as provided for in the law. This authorization expires in 90 days or upon termination of services provided by Alison Hadley, MSW/DCSW. I understand that this consent may be revoked at any time by presentation of a written revocation request to Alison Hadley, MSW/DCSW.

_______________________________________________________________

Signature of client or legal representative Date signed

________________________________________________________________

Relationship / Status, if signed by other than client

________________________________________________________________

Witness Signature Date release expires

Special consent must be given to release specific information regarding the following:

HIV/AIDS Sexually Transmitted Diseases Drug and/or alcohol abuse/dependence

____________________________/___________

Signature authorizes consent Date signed

Note: A general authorization for release of information is not sufficient for release of mental health records and information. / For children under the age of 13, a parent or guardian must sign. Children or adolescents age 13 and older sign for themselves.

Return: http://www.alisonhadley.com/bios.html