STEVE FRANKLIN, M.S.W., L.C.S.W.

6829 Gravois Ave.                                                                                                                                      314-517-8383

St. Louis, MO  63116                                               FAX 203-738-4036                                SteveFranklin@JUNO.com                                                                                                                          

                                                                                                                   

AUTHORIZATION FOR RELEASE OF INFORMATION

 

Your Name:  _______________________________________________SS #:____________________

 

Street:_______________________________________City_______________ ZIP Code___________

 

Organization or Person With Whom Information Will Be Exchanged

 

Organization _______________________________________________________________________

 

Name of Individual  __________________________________ Phone _____________________

 

Street:_______________________________City_____________State______ ZIP Code___________

 

o Information may be requested from the organization/individual 

o Information may be provided to the organization/individual        

 

Description of information to be exchanged.:______________________________________________

 

__________________________________________________________________________________

 

__________________________________________________________________________________

 

__________________________________________________________________________________

 

__________________________________________________________________________________

 

I consent to the release of the described information.  I may inspect and  copy the written information that is being exchanged, and I have the right to be told what information was exchanged in spoken communication.  The information will not be re-released to anyone without written authorization.  I understand that this consent may be revoked at any time by written notice.

 

Is there a termination date for this Authorization?       oYes:  Date____________ o No

 

 

________________________________________     _________ 

Client Signature                                                                      Date

 

________________________________________     _________ 

Therapist Signature                                                               Date

 

 

 

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