Life's Light in Counseling, Shannon West, LPC   -  Helping you find the Light in your Life
LIFE'S LIGHT IN COUNSELING, INC.
Shannon West, L.P.C., AADC, ICAADC, State Approved Supervisor for L.A.C.'s
State Approved Technology-Assisted Supervisor for L.A.C.'s
 State Approved Technology-Assisted Counselor
Qualified EMDR Therapist
479-530-8201


Authorization to Release Mental Health Care Information


Client's Full Name
Client's Date of Birth
I, being the client or guardian of the client named above request and authorize the release of the Mental Health Care Information checked below FROM Shannon West, L.P.C./Life's Light in Counseling, Inc. TO Name
Please provide the phone number of the person TO whom this information is to be released.
This request and authorization applies to:
All Mental Health Records
Diagnosis and Treatment Summary
Diagnosis and Treatment Recommendations
Presence in and dates of Treatment
Other
If you checked Other, please describe the information you would like released in detail
How would you like this information released?
Verbally
Written documentation/information
Verbally and/or Written
I understand that my express consent is required to release any Mental Health Care information relating to diagnosis, testing, mental health treatment, treatment for HIV, sexually transmitted diseases, psychiatric/mental health disorders, and/or drug and/or alcohol use.  I understand that this authorization expires one year after the date it is signed and may be revoked at any time upon written request of the client except to the extent that action has already been taken.I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations.  I understand that my refusal to sign this Authorization will not jeopardize my right to obtain present or future treatment except where disclosure of the information is necessary for the treatment. My treatment and payment for treatment will not be affected if I do not sign this form. I understand that I can request a copy of this form after I sign it. 
I understand that I may be asked to pay a fee of $0.50 per page depending on the type and length of the documentation to be released.

By signing below, I acknowledge that I have read and understand this Authorization. 

Signature of Client or Client's Guardian/authorized representative

Date Signed:  

Website Builder provided by  Vistaprint