(703) 530-9800
[email protected]

Release of Information

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Release of Information

This form is an agreement between you, and Calvary Counseling Center. When we use the word “you” below, it will mean you, your child, relative, or other person if you have written his or her name below:

PERSONAL INFORMATION

Name

Home Phone

Cell Phone

Email Address

I authorize

Actions

To send the following information to To receive the following information from

Authorized Personnel

#1

Name

Address

#2

Name

Address

#3

Name

Address

Items to be released (check all that apply)

Academic testing results Case notes Medical reports Progress reports Summary reports Intelligence testing results Behavior program Personality profiles Vocational testing results Entire record Psychological reports Service plans

Other

The above information will be used for the following purposes:

Planning appropriate treatment or program Continuing appropriate treatment or program Case review Determining eligibility for benefits or program Updating files

Other

I understand that I may revoke this consent at any time by providing written notice, and after one year this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information.

Client's Digital Signature

Parent/Guardian's Digital Signature

Calvary Counseling

CONTACT INFORMATION

(703) 530-9800
[email protected]
9430 Forestwood Lane, Suite 103, Manassas, VA 20110

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Release of Information